DTD Scholarship Application Form 2019

Dominate the Day Foundation is a non-profit organization established in memory of Jordan William Sebastian, an exemplary young man who valued education and athletics. In his honor, we are committed to helping young people become the absolute best version of themselves, through character, relationships, academics, sports and their positive impact on the world.

We encourage you to visit our website to learn more about our inspiration, our core values, our goals, and all of our past/future events. www.dominatethedayfoundation.com

We are offering tutoring scholarship stipends to area middle and high school students at Total Learning Group in Branford, CT www.totallearninggroup.com Each student accepted will receive a stipend towards tutoring services tailored to meet his/her needs.

If you are chosen as a scholarship recipient, then we are committed to supporting and mentoring you as a member of the first Dominate the Day student-cohort, but we need you to be committed as well. Your commitment expectations are as follows:

Keep all scheduled tutoring sessions with Total Learning Group (In emergency situations you will give as much notice as possible.)
Participate in Dominate the Day Workshops designed for and offered to your cohort.
Volunteer for at least one Dominate the Day event per year.

Name

First Name Last Name

Email

example@example.com

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number

Area Code Phone Number

Please list combined parent or total household annual income

What works best for your family? Select all that apply.

Onsite tutoring at Total Learning Group (80 East Main Street, Branford, CT) One-on one tutoring at local library FaceTime help

Full Name *

First Name Last Name

Birthdate: *

Month Day Year

Mobile No. : *

Area Code Phone Number

E-mail : *

Where the confirmation will be send to

Home Address : *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Demographic Information

Information regarding gender, ethnic origin and race are optional. The information is requested for post-scholarship report generation only and in no way affects your selection for scholarship awards.

Gender:

Male Female Other Identification

Background Demographics (Choose one or more)

White Black or African American Asian American Indian or Alaskan Native Hawaiian or Other Pacific Islander Hispanic and/or Latino

School Name

School Address and Phone

Guidance Counselor Name and Contact Information

Year of High School Graduation

Most Recent Cumulative GPA

School activities, community activities, volunteer work, honors, offices held:

In which classes do you excel?

In which classes do you struggle?

What type of learner are you?

Auditory (need to hear) Visual (need to see) Hands-on (need to do) Kinesthetic (need to move) I have no idea

What type of help do you need most?

Test Prep Subject/Content Area Tutoring Reading or Math Intervention Homework Help

Do you have an IEP or 504?

Yes No

If so, what are some of your teaching and learning modifications and/or accommodations?

Are you willing to share those documents with Total Learning Group and Dominate the Day?

Yes No

Total Learning Group keeps student growth data on file. If you are accepted, are you willing to share this data with Dominate the Day Foundation? (Student names will never be published anywhere by DTDF.)

Yes No

Please tell us briefly why you need a stipend towards tutoring or test preparation services. (What are your academic needs? What are your financial needs?) Are you able and willing to pay an additional portion to meet your child's academic needs?

Short Answer Form:

0/500

Volunteer Options

Dominate the Day 5K (June date TBD) Dominate the Day Football Camp (July Date TBD) Dominate the Day Holiday Give Back (Dec. TBD)) None of the Above

This should be signed by the parent. By signing (typing your legal name) in the space below, you are certifying that all information is accurate and honest. You are also agreeing to the student-expecations outlined above. When you press the submit button, you will receive an email confirmation that your application was received. Please print for your records and retain as verification of your application.

E-Signature: *

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Dominate the Day Scholarship Application

Instructions

DTD Scholarship Commitment Expectations

1. Parent or Guardian Information

2. Student Information:

3. School Information:

4. Student Learning Information:

6. Volunteer Interest

Applicant's E-Signature