DRAFT: Master Application - Apply for Scholarship

Applicant Information for Scholarship

* Indicates required field

I am applying for a scholarship for: *

SLC Scholarship Assistive Technology Scholarship Extracurricular Activity Support Scholarship

Name Of Student *

First

Last

Student E-Mail Address *

Student's Phone Number *

Student Mailing Address *

Line 1

Line 2

City

State

Zip Code

Country

Parent/Guardian Name (if applicable) *

First

Last

Parent/Guardian Phone Number *

Parent/Guardian Email Address *

Are you applying with an agency? If yes, please complete Agency contact information *

Yes No

If applying through an Agency, name of Agency *

Agency Phone Number *

Agency Contant *

First

Last

Agency Email Address *

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 individuals with intellectual disabilities a clear path to college by providing financial assistance for students 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.

Submit