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Pre-K Scholarship Application
Pre-K Scholarship Application
"
*
" indicates required fields
Step
1
of
5
20%
Is your child ELIGIBLE?
*
My child is currently 3-6 years old AND
I earn less than $116,055 annually (for each dependent child add $20,428)
Student Information
Last Name
*
First
*
M.I.
*
Date of Birth
*
MM slash DD slash YYYY
Gender
*
Male
Female
Other
Address
Street Address
Address Line 2
City
ZIP / Postal Code
STUDENT SCHOOL INFORMATION
Current School
*
Annual Tuition (include all required fees)
*
Amount of Assistance Requested
*
Parent / Guardian Information
1st Parent / Guardian’s Name
*
Relationship
*
2nd Parent / Guardian’s Name
*
Relationship
*
Address
*
Street Address
City
State / Province / Region
ZIP / Postal Code
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Bouvet Island
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Palestine, State of
Panama
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Pitcairn
Poland
Portugal
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Sint Maarten
Slovakia
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Solomon Islands
Somalia
South Africa
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South Sudan
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Sudan
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Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
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Tunisia
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Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
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Uruguay
Uzbekistan
Vanuatu
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Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Email Address
*
Home Phone
*
Work Phone
*
Current Marital Status
Single
Married
Divorced / Remarried
Divorced / Remarried
Widowed
Separated (Mo/Yr)
Other
Household Income Information
To be eligible for a scholarship, your annual household income (including income from all persons living in the household and any child support, alimony, public assistance, Supplemental Income including SSI, Disability Income, Social Security benefits or pensions) must not exceeed $92,160 plus $16,222 per dependent child. With this application, you must submit a copy of your Federal Income Tax Return (IRS Form 1040, 1040A, or 1040EZ) for 2022 with copies of all W-2 Forms and documentation of all other income sources. Any parent or guardian who claims the student as a dependent must report income on this application and attach the necessary documentation.
Income Sources
Gross income reported on Federal 1040 Forms:
1st Parent / Guardian
*
Additional Parent / Guardian
*
Total Household Income
*
Verification Signature
I certify that all of the included information is true and correct, all income is reported, and the income documents enclosed provide a true and accurate verification of my annual household income. I understand that the deliberate misrepresentation of the information may result in the scholarship being denied or terminated and may subject me to prosecution under State and Federal laws. I understand that the grant payments will continue for one year only as long as my child is enrolled at the school, my family continues to qualify under the scholarship income guidelines, and I stay current on the tuition balance. Any unused portion of the scholarship award, for whatever reason, must be refunded to Greater Pike Community Foundation (GPCF). Further, I understand that the scholarships are awarded according to the prioritized selection of the qualified applicants, as per the guidelines, and that the grant awards are the sole responsibility of GPCF, and all decisions are final. I agree to have my child's past and current progress reports released by the school to GPCF for program evaluation. I agree to release GPCF, and its Board of Directors and employees or partners, from any liability in its efforts to provide these educational grants which are renewable annually at the sole discretion of GPCF.
Signature of 1st Parent / Guardian
Social Security #
Date
MM slash DD slash YYYY
Signature of 2nd Parent / Guardian
Social Security #
Date
MM slash DD slash YYYY
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