Scholarship Application

Student Name*

First

Last

Date of Birth*

Child Lives With:*

Ethnicity: *

Your child lives with how many adults?*

Your child lives with how many other children?*

Have you applied for child care reimbursement through DHHS? *

Yes

No

Address

Street Address City State / Province / Region Postal / Zip Code Country

Parent/Guardian 1:*

First

Last

Phone*

c

Street Address City State / Province / Region Postal / Zip Code Country

Select those that apply

Working

Attending School

Other

Income Amount*

Chose the period, the above income represents:*

Weekly

Bi-weekly

Monthly

Annually

Parent/Guardian 2: *

First

Last

Address

Street Address City State / Province / Region Postal / Zip Code Country

Select those that apply*

Working

Attending School

Other

Income Amount*

Chose the period, the above income represents: *

Weekly

Bi-weekly

Monthly

Annually

Type your name(s) (first and last of parent(s)/guardian(s)) if you confirm that the information given is true to the best of your knowledge.*

Please understand that not all applications are granted. *

CLICK IF YOU HAVE ACKNOWLEDGED THIS STATEMENT

Email

Phone

Fax

Address