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Pre-K Scholarship Application
Applicant Information
Parent/Guardian First Name
Parent/Guardian Last Name
Relationship to Child:
Email
Phone Number
Street Address
City
State
Zip Code
Child’s Information
Child’s First Name
Child’s Last Name
Date of Birth
Age
School/Program Currently Enrolled:
Child’s First Name
Child’s Last Name
Date of Birth
Age
School/Program Currently Enrolled:
Child’s First Name
Child’s Last Name
Date of Birth
Age
School/Program Currently Enrolled:
Household and Income Information
Number of Adults in Household:
Number of Children (Under 18) in Household:
Total Annual Household Income (before taxes):
Income Sources:
employment
social security
business income
alimony
child support
Verification of Income (Attach copies) eg. Most recent pay stubs or income statements
Does your household receive any of the following?
SNAP (Supplemental Nutrition Assistance Program)
Medicaid or CHIP (Children's Health Insurance Program)
TANF (Temporary Assistance for Needy Families)
SSI (Supplemental Security Income)
Housing Assistance
Please explain any unique financial burdens, such as medical expenses, debt obligations, or other significant financial responsibilities:
Educational and Career Goals
Why do you believe your child would benefit from a pre-K scholarship?
What are your child’s educational and developmental needs?
Please describe any unique challenges or circumstances that impact your family’s ability to pay for pre-K education:
Program Preferences
Preferred Pre-K Program/School Name:
Program Address:
Program Contact Information:
Estimated Tuition Cost
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