Earn-learn-Stipend-Form

Stipend Award Acceptance Form

To receive an Earn and Learn Stipend, you must complete this form no later than May 10, 2023. To select your preferred stipend payment method, please complete, sign, and return the acceptance form to the Earn & Learn Program Administrators

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Are you under the age 13? *parent or legal guardian must sign this form if under the age of 18*

Which Program/Track are you Joining?

Do you have a bank account that can accept electronic fund deposits on a regular basis for the duration of this program?

How would you like to receive your educational stipend from the Earn & Learn Program?

Acceptance and Certification

I accept the offer of an educational Stipend Award in exchange for agreeing to fully participate and consistently attending the Earn and Learn track/program of my choice. I agree to comply with the rules governing it as set forth in the Healthy Together Earn & Learn Participant Handbook. I acknowledge as with any bank deposit, it is important to verify the bank balance before writing checks on any direct deposit accounts I use or setup to receive a stipend from the Earn and Learn program. The Earn & Learn program is not responsible for any NSF (Non-Sufficient Funds) fees my account may incur and is my responsibility, even if/when an expected payment did not occur or was recalled. I certify that the information submitted in this form is true and correct to the best of my knowledge and that any changes or additions will be promptly reported to the Healthy Together Earn & Learn Program Facilitator(s).

Name

First NameLast Name

Signature

Date

Print Name of Parent/Guardian

Signature of Parent/Guardian (or write not applicable)

Date