Scholarship Application Family Information Question Title * 1. Parent/Guardian Name(s): (Required.) Question Title * 2. Relationship to Child: (Required.) Question Title * 3. Home Address (Required.) Question Title * 4. Phone Number (Required.) Child Information Question Title * 5. Child’s Full Name: Question Title * 6. Date of Birth: (Required.) Date Date Question Title * 7. Program Enrolled/Enrolling In: (Required.) Infant (up to 12 months) Young Toddler (1 to 2 Years) Older Toddler (2 to 3 Years) Preschool (3 YRS to Kindergarten Entry) Kindergarten School Age (1st thru 6th grade Household Information Question Title * 8. Number of Adults in Household: (Required.) 1 2 3 4 5 6 7+ Question Title * 9. Number of Children in Household: (Required.) 1 2 3 4 5 6 7+ Question Title * 10. List all household members and relationship to child: Name Age Relationship (Required.) 1 2 3 4 5 6 7 8 9 10 Employment & Income Information Question Title * 11. Parent/Guardian Employer: (Required.) Question Title * 12. Work Phone: (Required.) Question Title * 13. Hours per Week: (Required.) Question Title * 14. Income Amount (Required.) Question Title * 15. How often are you paid? (Required.) Daily Weekly Bi-Weekly Semi-Monthly Monthly Other Question Title * 16. Parent/Guardian Employer: Question Title * 17. Work Phone: Question Title * 18. Hours per Week: Question Title * 19. Income Amount Question Title * 20. How often are you paid? Daily Weekly Bi-Weekly Semi-Monthly Monthly Other Question Title * 21. Other Household Income Sources (check all that apply) (Required.) Child Support SSI/Disability Unemployment Other None Question Title * 22. Frequency: Weely Bi-Weekly Semi-Monthly Monthly Question Title * 23. Total Household Income (from all sources): Question Title * 24. Assistance Currently Receiving (Required.) Child Care Works / Subsidy / ELRC / CCIS Snap (Food Stamps) WIC TANF Housing Assistance None Scholarship Request Question Title * 25. Amount of Assistance Requested: $__________________ per month/week (Required.) Question Title * 26. Reason for Request: (Required.) Supporting Documentation Please attach the following: Question Title * 27. Child Care Works Denial Letter (Required.) Question Title * 28. Most recent pay stubs (last 4 weeks) for all working adults in the household (Required.) Question Title * 29. Most recent tax returns or W-2s for all working adults in the household (Required.) Question Title * 30. Proof of other benefits or assistance programs Question Title * 31. Any additional documentation supporting your financial need Agreement & Signature I certify that all the information provided is true and complete to the best of my knowledge. I understand that:Providing false information may result in the denial or termination of scholarship assistance.Scholarships are contingent on continued enrollment, attendance, and adherence to Bright Little Scholars policies.I am responsible for paying any remaining tuition balance not covered by the scholarship. Question Title * 32. Parent/Guardian Signature Done
