Scholarship Application Form

Scholarship Application Form
Child's Full Name

First NameLast Name
Child's Gender

MaleFemale
Date of Birth

MonthDayYear
Date
Scholarship Amount Requested Weekly
$

Family Information
Parent 1
Parent Name

First NameLast Name
Home Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent 2
Parent Name

First NameLast Name
Home Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Other children in family
Configurable list*

Additional Information
Monthly Family Income (Gross)
$

Additional Income

	Income ($)
Welfare AFDC
Child Support
Support from Spouse
Social Security
Income from 2nd Job
Other
Total Additional Income

Total Monthly Income
Do you receive benefits from?

FoodstampsMedicaidWICDaycare Assistance
Please Explain the Reasons for Need
I certify that all the information provided is true and accurate to the best of my knowledge. I understand that all apllications will be reviewed by the board and evaluated based on a need basis.
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