Applicant Information Request for Assistive Technology

* Indicates required field

Name Of Applicant *

First

Last

Parents/Gardian Name *

First

Last

Home Phone Number *

Cell Phone Number *

E-Mail Address *

Applicant's Address *

Line 1

Line 2

City

State

Zip Code

Country

Due to the unique nature of our educational support we request all applicants personally articulate their intentions to the best of their ability. In your own words please tell us why you are requesting this scholarship. *

The purpose of Clary Garden is to provide a clear path to education and social opportunities by providing financial assistance for those who want to continue to learn but are experiencing financial difficulties. *

I confirm the information submitted on this form is accurate. The statements provided by potential recipients have been honestly represented.

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