Scholarship Application
To be completed by Adult Participant or Parent/Legal Guardian
Name
First Name
Middle Name
Last Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Scholarship awards are based on household income, household size, and available scholarship funds.
Annual Combined Household Income (Include the income of all adults living in the household before taxes.)
$0 - $35,000
$35,001 - $60,000
$60.001 - $85,000
$85,001 +
How many people live in the household?
Participant(s) requesting a scholarship(s): (List the name(s) of each rider requesting scholarship assistance.)
Are there other financial considerations?
Yes
No
If Yes, please explain
The information on this Scholarship Application is complete and true to the best of my knowledge.
Submit
Submit
Should be Empty: