All scholarship applicants must provide the following information with application submission: *Individual photo(optional) * Proof of income *Copy of completed registration or Camp or Coach information and contact person Applications must be submitted two weeks prior to event or start date to allow time for processing.
Part 3. Foster Child
If this application is for a child who is the legal responsibility of a welfare agency or court, list the amount of the child's personal use monthly income: $
Part 4. Total Household Income from Last Month -- You must tell us how much and how often
1. Food Stamp Case # - ( if applicable)
If food stamp case number was entered, provide proper DHS verification.
(List EVERYONE in household)
First Last
Age
Gross Income / How often received
Welfare, child support, alimony
Pensions, retirement, Social Security
Other
Check if no income
Jane Doe (Example)
30
$300/ bi-monthly (Ex)
$150/weekly (Ex)
$600/monthly (Ex)
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Part 5. Signature and Personal Information
Today's Date: Contact Person: Email: Home Phone # Work # Message # Street Address : City: State: Zip:
Part 6. Demographic Information
Name of School
County of Residence
Part 7. Child's racial and ethnic identities (optional)
Caucasian
African-American
Native American
Native Hawaiian
Hispanic or Latino
Asian
Multi-Racial
Other Pacific Islander
By submitting this application: I certify (promise) that all information on this application is true and that all income is reported. I understand that Crutchfield Charities officials may verify
