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Confidential Scholarship Application

Participant Information

First Name *

Last Name *

Date of Birth *

Gender

Primary Disability *

Parent/Guardian Name *

Address *

City *

State *

Zip *

Phone *

Email *

Household Information

Number of individuals living in the household *

Number of household individuals employed *

Does anyone living in your household receive income from any of the following?
(check all that apply and specify amount)

Social Security

Social Security Per Month

SSI Disability

SSI Disability Per Month

Employment

Employment Per Month

Workman’s Compt

Workman’s Comp Per Month

Child Support

Child Support Per Month

Pension

Pension Per Month

Unemployment Comp

Unemployment Comp Per Month

Public Aid

Public Aid Per Month

Foster Parent (DCFS)

Foster Parent (DCFS) Per Month

Household Monthly Income

Does anyone in your household participate in the Free or Reduced Price School Lunch Program? *

Yes

Do you regularly experience (or have you recently experienced) any unusual medical expenses? *

Yes

Please provide medical expense details

Are there any other unusual household expenses at this time?

Program Information

Program Title 1 *

Program Title 2

Total Fees *

The portion of the fee that I can pay *

The dates by which I can make payments are:

Date 1 *

Date 2 *

Date 3 *

Date 4 *

Additional payment dates may be arranged to meet your needs.

Authorization

I have read and understand the Scholarship Policies.

I understand that all information given is not a matter of public record and all information will be kept confidential.

I will make SSSRA aware of any changes in our financial status. All of the information I have provided is accurate.

Signature *

By checking this box, you agree to a digital signature, and this digital signature shall substitute for and have the same legal effect as an original form signature

The SSSRA Scholarship Policy is as follows:

Scholarships are for residents with disabilities only.
Deposit is required for scholarships.
Scholarships are based on need and the availability of funds.
Scholarships are usually awarded for a maximum of two programs per season.
The maximum scholarship award is 50% of the fee for each program. The amount of the award may be less than 50% of the fee.
No scholarships are awarded for Summer Day Camp Transportation, unless stated otherwise in the summer brochure.
All balances are due by the registration deadline of the following season.