Hollister MOMS Scholarship Application

1

Name* This field is required.

First Name

Last Name

2

Phone Number* This field is required.

Area Code

Phone Number

3

Email* This field is required.

example@example.com

4

Address* This field is required.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

5

ChildrenLeave extra fields blank

Child #1 Name

Child #1 Date of Birth

Child #2 Name

Child #2 Date of Birth

Child #3 Name

Child #3 Date of Birth

Child #4 Name

Child #4 Date of Birth

6

I am requesting that the MOMS SEMESTER registration fee of $70 per year be reduced by:* This field is required.

$25 off

$50 off

$70 off

7

I am requesting a waiver of the above fee because:* This field is required.Check all that apply

I am a single mother

I am the wife of a deployed, enlisted soldier

Both my husband and I are unemployed

I have major medical expenses

My family is considered “low income” by California standards

Other

8

Please explain the nature of your hardship and why you are requesting a scholarship:

9

Are you currently employed?* This field is required.

YESNO

10

Current Employer* This field is required.

11

Marital Status* This field is required.

Unmarried

Married, Husband Employed

Married, Husband Unemployed

12

Spouse's Information* This field is required.

Full Name

Occupation

Current Employer

13

Any additional comments:If none, skip question

14

Are you willing to volunteer to give back?* This field is required.

YESNO

15

I certify that all the above is true and correct and I am in need of a financial scholarship for the MOMS year.* This field is required.