PROJECT SMASH: Scholarship Application Form

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SCHOLARSHIP APPLICATION
Student Legal Name

First NameMiddle NameLast Name
Student Preferred Name
Nickname
Parent/Legal Guardian(N/A if you are the student)

PrefixFirst NameLast NameSuffix
Student's Date of Birth

MonthDayYear
Date
Relationship
Relationship to Student
Are you applying for yourself or your child?
Email
example@example.com
Phone Number

Area CodePhone Number
Student Address

Street Address

Apt/Unit/Suite Number

CityState

Zip Code

HOUSEHOLD INFORMATION
HOUSEHOLD SIZE
Number of Persons in Household
Annual Household Income
Gross Income (before Deductions) per Year
Does Your Family Receive Any Type of Assistance? (Check all that apply)

Other
Upload copy of : PROOF OF GOV. ASSISTANCE- WIC, SNAP, MEDICAID-DOCUMENTS ONLY! (NO PERSONAL PHOTOS)

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FINANCIAL INFORMATION
Is Scholarship Needed Due to a Temporary Financial Hardship?
In A Few Sentences, Please Describe Your Current Financial Circumstances
How long would you need the scholarship for?/ How much aid would help? (Partial scholarships available too)
This will help us better determine how much you will recieve.

INDENTIFYING DEMOGRAPHICS

(Optional: Providing the Identifying Information; as requested in this section, assists us understand and collect demographic Information used to continue to provide scholarships to our community in need.)
Student Date of Birth

MonthDayYear
Date
Student Gender

Other
Student Ethnicity (this helps us when we apply for grants)

Other

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.
Applicant's Signature
Name of Applicant

First NameLast Name
Date Signed by Applicant

MonthDayYear
Date
Should be Empty:

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