Parent/Guardian Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Child's Name *

First Name

Last Name

Child's Gender *

Male

Female

Child's Date of Birth *

MM

DD

YYYY

Employment Status *

Employed

Self-employed

Student

Disabled

Retired

Unemployed

Additional Assets *

Check all that apply

Stocks

Bonds

401k

HSA

Trusts

Property (excluding primary residence)

None

*

I understand that scholarship funding is subject to an approved Intake form. Families may be eligible for full or partial scholarships.

*

I understand that completing this form does not guarantee that I will qualify for scholarship funding. Priority is given to families with the greatest financial need.

*

I understand once all donated funds are used, remaining families will be put on a waitlist for future scholarship opportunities.

*

I understand the scholarship is conditional on an approved Intake Form.

*

I affirm that the above information is true and correct to the best of knowledge, and if information is found to be false, the result will be the denial of financial assistance.