CISV Austin Scholarship Application

CISV Austin San Antonio Scholarship Application
NAME OF YOUTH DELEGATE APPLICANT
HOME ADDRESS
CITY STATE ZIP
HOME PHONE
DATE OF BIRTH
TODAY'S DATE
SCHOOL ATTENDING
GRADE
PROGRAM APPLYING FOR: VILLAGEJ.C. FORTNIGHT
MOTHERS NAME
HOME PHONE
HOME ADDRESS
IF DIFFERENT THAN CHILDS
OCCUPATION
EMPLOYED BY
FATHERS NAME
HOME PHONE
IF DIFFERENT THAN CHILDS
OCCUPATION
EMPLOYED BY
PARENTS' MARITAL STATUS
IF SEPARATED OR DIVORCED WHO IS CUSTODIAL PARENT
NAMES AND CURRENT AGES OF BROTHERS OR SISTERS
TOTAL NUMBER OF FAMILY AND NON-FAMILY MEMBERS AT HOME/EXPLAIN
TOTAL NUMBER OF FAMILY MEMBERS NOT AT HOME EXPLAIN IE AWAY AT COLLEGE
FAMILY'S GROSS ANNUAL INCOME FOR PAST 2 YEARS:
LAST YEAR:
PREVIOUS YEAR
OWN HOMEAMT OF MONTHLY MORTGAGE
RENTAMT OF MONTHLY PAYMENT
OTHER PLEASE EXPLAIN
IF APPLICABLE, MONTHLY AMOUNT OF ALIMONY $
ALIMONY
PERSONAL FUNDS AVAILABLE FOR THIS CISV EXPERIENCE
EXPLAIN THE CIRCUMSTANCES THAT MAKE IT NECESSARY TO REQUEST SCHOLARSHIPFINANCIAL ASSISTANCE ATTACH ADDL PAGE IF NECESSARY TO PROVIDE COMPLETE EXPLANATION
FUNDS AVAILABLE FOR THIS CISV EXPERIENCE FROM FRIENDS/RELATIVES $ EXPLAIN THE CIRCUMSTANCES THAT MAKE IT NECESSARY TO REQUEST SCHOLARSHIP/FINANCIAL ASSISTANCE (ATTACH ADD'L PAGE IF NECESSARY TO PROVIDE COMPLETE EXPLANATION):
LIST ANY CONTRIBUTIONS YOU HAVE MADE TO CISV IE MONETARY VOLUNTEERING TIME INKIND CONTRIBUTIONS LEADERSHIP ROLES ETC
APPROXIMATE DOLLAR AMOUNT OF SCHOLARSHIP REQUESTED
I (We) agree to accept the decision of the Executive Committee. I (We) understand that all application information will be kept strictly confidential by the Scholarship Committee and Executive Committee, and that we are not to disclose any information to others regarding scholarship awards. I (We) also commit to support the Chapter with my (our) volunteer support during the next two years. In the future, if I (We) are able to provide a donation to the Scholarship Fund, we will do so in order to help another deserving young person to participate. I (We) verify that all information provided in this application is, to the best of my (our) knowledge, accurate and complete.

STATEMENT OF PARENTS OR GUARDIAN(S)
MotherGuardian
date

MonthDayYear
Date
FatherGuardian
date

MonthDayYear
Date
Should be Empty:

DATE OF BIRTH

TODAY'S DATE

HOME ADDRESS

PARENTS' MARITAL STATUS

NAMES AND CURRENT AGES OF BROTHERS OR SISTERS

TOTAL NUMBER OF FAMILY AND NON-FAMILY MEMBERS AT HOME/EXPLAIN

FAMILY'S GROSS ANNUAL INCOME FOR PAST 2 YEARS:

LAST YEAR:

FUNDS AVAILABLE FOR THIS CISV EXPERIENCE FROM FRIENDS/RELATIVES $ EXPLAIN THE CIRCUMSTANCES THAT MAKE IT NECESSARY TO REQUEST SCHOLARSHIP/FINANCIAL ASSISTANCE (ATTACH ADD'L PAGE IF NECESSARY TO PROVIDE COMPLETE EXPLANATION):

APPROXIMATE DOLLAR AMOUNT OF SCHOLARSHIP REQUESTED