MCS~Fund Scholarship Application
2060 West 65th Street Cleveland, Ohio 44102 Phone: 216)466-3801 Email: MCSaxton.Funds@gmail.com
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Application
Please fill out application out completely or the application will NOT be processed
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Name
*
First Name
Last Name
Intake Date
*
-
Month
-
Day
Year
Date
Birthday
*
-
Month
-
Day
Year
Date
Age
*
SOCIAL SECURITY# (INCLUDE ONLY LAST FOUR DIGITS; EX. XXX-XX-9999)
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Marital status:
Please Select
S
M
D
W
Signature
*
Referred by:
*
Name of Agency Director/Licensed Social Worker
*
Signature of Licensed Social Worker
*
Agency Name and Address:
*
Agency Phone Number
*
Please enter a valid phone number.
Agency Fax Number
Please enter a valid phone number.
Are you...
*
Individual with sickle cell disease (SCD)
Parent/Legal Guardian/Caregiver of Individual with SCD
Spouse of Individual with SCD
Member of a local Sickle Cell Support Group
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*If this is a utility request, please provide the client’s most updated utility bill.
Income of applicant
Current Employer
Position:
Monthly Salary
Please indicate if your client receives any of the following (Please check all that apply.):
*
SNAP
SSI
SSDI
OTHER
CHILD SUPPORT
VENDOR INFORMATION: Please fill out vendor information completely (NOTE: checks are never made out to applicants.)
COPY OF INVOICE, UTILITY BILL OR LEASE AGREEMENT MUST BE INCLUDED WITH THIS APPLICATION
** Fed. TAX I.D. for vendor must be included (For Sole Proprietor/ Landlord, Social Security No. may be used.
**Name of Vendor
**Address Of Vendor
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
**Vendor Phone Number
Please enter a valid phone number.
Amount Requested (Max $150)
Should be Empty: