Giving Hope & Help Education is Your Passport Scholarship Program Application

Uplifting Parents Full Application
Mission: To create stability and greater opportunities for single parent families through relationship-based mentoring and wraparound supports throughout their higher-education journey.

Uplifting Parents works to meet our mission through five key program components:
- Relationship-based mentoring
- Financial support (through education and a monthly stipend)
- Academic Support
- Parenting Resources
- Career Readiness
UP participants are matched with an Uplifting Parents Mentor who helps anticipate and intercept potential crises that could derail their success. Mentoring is the heart of the program and helps provide the holistic services and support that will assist you in completing your degree or certification and achieving economic stability for your family.
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The Application will take about 30 minutes to complete. You are able to save your work and return to the application as necessary.

If you have questions or difficulties in completing the application, please contact us by phone (605-348-6086) so we can assist you.

We will not be able to view your application until you have submitted it.

Completed applications are due within 10 days of receiving the application link. Please be on the lookout for information from us (by phone or email) on your next steps in the next 5-7 business days.

APPLICANT INFORMATION
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County*
Email Address*
example@example.com
Re-enter Email Address*
example@example.com
Phone Number*

Area CodePhone Number (000-0000)
Your Date of Birth*

MonthDayYear
Date
Please enter the last 4 digits of your social security number*
This will only be used for identification purposes in data collection.
What is your gender?*
Please select your racial or ethnic background from the options below:*
If you selected 'Other' above, please provide an explanation or specify your racial or ethnic background.
YesNo
If 'yes,' please provide approximate dates of participation.
YesNo
If 'yes,' please provide approximate date of application and brief explanation of why you did not participate.

REFERRAL

Uplifting Parents program is a referral program that requires you to be referred into our program. This person can be how you heard about our program but should also know you well enough to answer some questions related to their knowledge of you, your history, your motivation, your resources, etc. Please provide 2 referrals, one must be from an academic institution and referrals must not be family members or be a self-referral
First Referral Name*

First NameLast Name
Email*
example@example.com
Organization*
Second Referral Name*

First NameLast Name
Email*
example@example.com
Organization*

HOUSEHOLD INFORMATION
Total Number of Household Members (including yourself)*
Example: If there are five people living in the same home, select the number 5.
Of the total household members indicated above, how many of these are in your immediate family? (Immediate family consists of one's parents, siblings, spouse, and children.)*
This total number does NOT include yourself.
What is your legal marital status? *
For your housing, are you currently: *
If 'other,' please explain your housing situation:
How many children do you have? *
Include your biological children and those adopted or whom you have legal guardianship.
YesNo
If 'yes,' how many and what is your relationship to them?

Child Information
Child #1 Full Name

First NameLast Name
Child #1 Date of Birth

MonthDayYear
Date
Child #2 Full Name

First NameLast Name
Child #2 Date of Birth

MonthDayYear
Date
Child #3 Full Name

First NameLast Name
Child #3 Date of Birth

MonthDayYear
Date
Child #4 Full Name

First NameLast Name
Child #4 Date of Birth

MonthDayYear
Date
Child #5 Full Name

First NameLast Name
Child #5 Date of Birth

MonthDayYear
Date
Child #6 Full Name

First NameLast Name
Child #6 Date of Birth

MonthDayYear
Date
YesNo, I have fully subsidized childcareNo, family/friends watch my child(ren) at no costNo, my children are old enough to not require childcareOther
If 'yes,' enter the childcare provider.
If 'yes,' enter the total monthly amount you pay each month for childcare.

Is there anything else we should know about you? Please feel free to write in any additional information that would be helpful for us to know.
I agree that all information completed on this application is complete and true. To the best of my knowledge, I meet all eligibility requirements for Uplifting Parents.

I agree to notify Uplifting Parents in the event any of the circumstances/information included in this application changes.

Once submitted, I understand that I will be contacted by an UP mentor to schedule an interview.

I also understand that completion of this application does not guarantee or imply admission to the program.
Date*

MonthDayYear
DateHourMinutesAM/PM Option
Signature of Applicant*
Should be Empty:

Uplifting Parents Full Application