Summer Programs Scholarship Application

Summer Programs Scholarship Application
The Terre Haute Children’s Museum Scholarship Program was created to give children the opportunity to participate in the Museum’s educational programs, regardless of financial circumstances.

• Full and partial scholarships may be awarded to students on the basis of financial need and desire to participate. Financial need must be demonstrated as indicated on the scholarship application.

• Scholarships are limited and will be awarded to eligible students on the basis of space availability.
Child's Full Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Child's Gender

Male Female
School *
Grade in Fall *
Which Summer program are you wanting the scholarship for? (Check all that apply.) *

Everyday Science Club Museum in the Park

Family Information
Parent Name *

First Name Last Name
Email *
example@example.com
Home/Cell Phone *

Area Code Phone Number
Work Phone

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Number of Adults in Household *
Number of Children in Household *
Please check any forms of assistance you receive. (check all that apply)

WIC SSI School Lunch Program SNAP Medicaid or Medicare

Additional Information
Monthly Family Income *
$
Please Explain the Reasons for Need *
Parent Signature By signing this I verify this information is true and correct to the best of my knowledge and belief.

Clear
Should be Empty:

Family Information