The Next Step Scholarship Success Program Registration

The Next Step Scholarship Success Program Registration

Start Early. Stay Focused. Succeed Always.
Student Information
Student First Name
Student Last Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Grade Level
School Name
School District
Student Email Address (if applicable)
example@example.com
Student Phone Number (optional)
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Information
Parent/Guardian Name
Relationship to Student
Parent Email Address
example@example.com
Parent Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Preferred Method of Communication
Home Address
City
State
Zip Code
Program Information
How did you hear about the program?

Other
Has the student ever applied for a scholarship before?
Has the student received any scholarships in the past?
If yes, approximate scholarship amount received
What is the student's current educational goal?

Other
Does the student currently participate in any of the following?(Check all that apply)

Other
I give Richelle's Heart permission to photograph and/or record my child for program, marketing, grant reporting, social media, website, and promotional purposes.
I understand that this program requires active participation and that scholarship opportunities may require work outside of program meetings.
I understand that attendance and participation may be tracked for future recognition opportunities and scholarship incentives.
I understand that participation in this program does not guarantee scholarship awards or financial assistance.
The Next Step Scholarship Success Program meets every other Tuesday from 6:30 PM – 7:30 PM at the Como Community Center starting September 8, 2026. I understand the meeting schedule and agree to participate to the best of my ability.
Emergency Contact
Emergency Contact Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Would you like to receive information about future Richelle's Heart programs and opportunities?
Program Participation Acknowledgment & Release
By submitting this registration form, I acknowledge that I am the parent, guardian, or authorized representative of the student listed above and give permission for participation in The Next Step Scholarship Success Program presented by Richelle's Heart, Inc. I understand that: Participation in this program is voluntary. The program is designed to provide scholarship education, resources, guidance, and support. Participation does not guarantee scholarship awards, financial assistance, college admission, or acceptance into any educational institution. Students are responsible for completing scholarship applications, meeting deadlines, and submitting all required documentation. Richelle's Heart, Inc., its staff, volunteers, facilitators, partners, and program representatives are not responsible for decisions made by scholarship providers, colleges, universities, or other organizations. Attendance, participation, scholarship applications submitted, scholarships awarded, and program outcomes may be tracked for reporting, evaluation, recognition, and future funding purposes. Photographs, videos, testimonials, and program activities may be used by Richelle's Heart, Inc. for educational, promotional, website, social media, marketing, fundraising, and grant reporting purposes unless otherwise requested in writing. Every effort will be made to provide a safe, positive, and supportive environment for all participants. However, Richelle's Heart, Inc., the Como Community Center, program facilitators, volunteers, and partners shall not be held liable for accidents, injuries, loss of personal property, or circumstances beyond their reasonable control. Participants are expected to conduct themselves respectfully and follow all program rules and expectations. Failure to do so may result in removal from the program. By checking the box below and submitting this form, I acknowledge that I have read, understood, and agree to the terms outlined above.
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The Next Step Scholarship Success Program Registration

Student Information

Parent/Guardian Information

Program Information

Emergency Contact

Program Participation Acknowledgment & Release