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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
Our total household income is 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
Student Address
*
Address Line 1
Address Line 2
City
State / Province / Region
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
*
1st Parent / Guardian Email Address
*
1st Parent / Guardian Home Phone
*
Current Marital Status
Single
Married
Divorced / Remarried
Widowed
Household Income Information
To be eligible for a Pre–Kindergarten Scholarship, your total 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 exceed $112,348 plus $19,775 per dependent child.
With this application, you must submit a copy of your Federal Income Tax Return (IRS Form 1040, 1040A, or 1040EZ) for the most recent tax year, along 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.
1st Parent / Guardian Annual Income
*
Additional Parent / Guardian Income
*
Total Household Income
*
Please upload a copy of your Federal Income Tax Return (IRS Form 1040, 1040A, or 1040EZ) for the most recent tax year, along with copies of all W-2 Forms and documentation of all other income sources.
*
Max. file size: 512 MB.
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.
Parent / Guardian Name
*
Date
*
MM slash DD slash YYYY
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