Randon Costello Scholarship Form

Randon Costello Scholarship Form
DSW (Parent/Guardian) Information

Please complete the following information about the child’s parent or guardian who works as a DSW.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Format: (000) 000-0000.
Select Your LHCLA Office Location*
How long have you worked for Leading Home Care?*
(For example: "4 years")
YesNo

Randon Costello Scholarship Form
Child of DSW Information

Please complete the following information about the child of the parent or guardian who works as a DSW.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Grade Level or Year in School*
If other, specify here:
Name of School*
Relationship to DSW*
(For example, "child", "stepchild", etc.)

Randon Costello Scholarship Form
Tuition Request
What is the total amount of tuition you are requesting?*
(For example, "$5,000")
Upload Proof of Enrollment*

(For example, a copy of the child's latest report card, a school ID card, etc.)
Cancelof
NOTE: After your application is received, a member of your local office will contact you to verify tuition costs by requesting a statement or invoice.

Randon Costello Scholarship Form
Tutoring Costs Request

Leading Home Care partners with Sylvan Learning for tutoring services as they have locations in almost all LHCLA locations. However, any licensed, professional tutor may be used after qualifications have been verified.
Tutor or Tutoring Company Name*
(For example, "Sylvan", or "Jane Smith")
Estimated Monthly Cost of Tutoring*
(For example, "$750")
NOTE: After your application is received, your local office will reach out to confirm the tutoring services and associated costs.

Randon Costello Scholarship Form
Short Answer

Students in 6th grade and above: Submit an essay explaining how this scholarship will support your academic success.
Submit your essay* here:
*Required for application to be considered complete for children in 6th grade or higher.

Randon Costello Scholarship Form
I CERTIFY THAT ALL STATEMENTS OR INFORMATION I HAVE PROVIDED ABOVE ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. ANY DELIBERATE MISREPRESENTATION FOUND IN THIS APPLICATION MAY BE CAUSE FOR THE APPROVAL OF THIS APPLICATION AND MAY PROHIBIT ME FROM APPLYING AGAIN IN THE FUTURE.
Name of Applicant*

First NameLast Name
Applicant's Signature*

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Date Signed by Applicant*

MonthDayYear
Date
Should be Empty:

DSW (Parent/Guardian) Information