Bacon Bash Texas Type 1 Diabetes CGM Scholarship Application

2024 CGM Scholarship Application

Bacon Bash Texas
Eligibility
- All applicants must be under the age of 18 and diagnosed with Type 1 Diabetes to qualify for camp scholarships.
- Scholarship applications must be submitted by November 30, 2023 for consideration for the 2024 year.
- Only requests submitted on this form will be considered for funding.
- Applications must be completed in full, and include all required attachments, at the time of submission.
Application
Applicant Name*

First NameLast Name
Birthday*

MonthDayYear
Male / Female*

MaleFemale
Date Diagnosed with Type 1 Diabetes*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How will a CGM unit help you?*
To be Completed by Student
What is the hardest part about living with Type 1 Diabetes?*
To be Completed by Student
Photo of Applicant:*

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CGM Information
Is applicant currently using a CGM?*
Has applicant previously used a CGM?*
Does your health insurance cover a portion or all of the cost of a CGM?*
Signed Physician Acknowledgement Form*

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Parent/Legal Guardian Information
Parent/Legal Guardian Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email*
example@example.com
Address (if different from Applicant's)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Permissions*

If my child is selected for a scholarship, I give Bacon Bash Texas permission to use my child's photo, first name, age, and state, as well as quotes from our responses* on this application for promotional purposes. Featured locations could include, but are not limited to, printed materials, website features, social media, and e-mail newsletters. (*Financial information and intimate details will be kept confidential.)No, thank you.
How will applicant/your family benefit from a CGM system?*
To be Completed by Parent / Guardian
Please make a brief statement describing why your child is in need of financial assistance. *
To be Completed by Parent / Guardian
What is your occupation / job title? *
What is spouse's occupation? *
The answers provided below are to be transferred from your most recent 1040, which will also need to be uploaded below.

What is the combined/total annual household income: Check the appropriate box. *

	Under $20,000	$20,000-$40,000	$40,000-$60,000	$60,000-$80,000	$80,000 and up
Income

Number of Dependents*
Line 6C on 1040, Line 5on 1040 EZ or Line 6C on 1040A.
Total Income*
Line 22 on 1040 or Line 15 on 1040 A.
Adjusted Gross Income*
Line 37 on 1040, Line 4 on 1040 EZ or Line 21 on 1040 A.
List Special Circumstances (If Any)
Most Recent 1040 or letter explaining exemption.*

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By signing this document, I agree that the information provided is accurate.
Parent/Legal Guardian Signature*

Clear
Please Note: Financial assistance is not guaranteed. Assistance will be given based on the availability of funds and level of need.

Scholarships will be awarded no later than January 2024, based on need and with priority given to applications submitted by the deadline.

Parents/legal guardians will receive scholarship notification (for both approved and declined applications) by e-mail no later than January 2024. Scholarship payments will be made directly to CGM vendor.
Should be Empty:

2024 CGM Scholarship Application

Eligibility

Application

CGM Information

Parent/Legal Guardian Information