Scholarship Form
* Indicates a required field
Student's Name *
Age *
Birthdate
Address Line 1 * (for all Correspondence)
Address Line 2
City *
State *
Zip Code *
Name of Parent / Step-Parent / Guardian #1 *
Email Address *
Daytime Phone *
Evening Phone
Occupation / Employer *
Work Address Line 1
Work Address Line 2
City
State
Zip Code
Monthly Earnings (BEFORE taxes) *
Additional Monthly Household Income
(include ALL sources: alimony or support from
non-custodial parent, Veterans/Social Security
benefits, unemployment or workers’ compensation,
federal or state aid, etc.)
Name of Parent / Step-Parent / Guardian #2
Daytime Phone
Evening Phone
Occupation / Employer
Work Address Line 1
Work Address Line 2
City
State
Zip Code
Monthly Earnings (BEFORE taxes)
Additional Monthly Household Income
(include ALL sources: alimony or support from
non-custodial parent, Veterans/Social Security
benefits, unemployment or workers’ compensation,
federal or state aid, etc.)
Marital Status (Married / Single / Divorced)
Total number of people living in the student applicant’s household
Please state what class or camps your child is interested in
and why you think he or she is a good candidate
for this scholarship.