| Whole Children and Milestones

Scholarship Request Form

Please Note: Families may only request one scholarship for one (1) class per session (Fall, Winter, Spring, Summer or Vacation Week Sessions). Scholarships rarely cover the entire cost of the class. Payment plans are also available. Please fill out all the fields below and submit.

Student's Name: *

First

Last

Date of Birth: *

Contact Name: *

First

Last

Relationship to Student: *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Phone

Class Name: *

Starting Date: *

Class Fee: *

Do you currently qualify for income based free or reduced lunch or other public assistance programs? *

If you answered "yes" above, please clarify which one(s):

Amount of Scholarship Requested: *

(i.e., 25% to 75% of class cost)

Brief description of circumstances and verification of scholarship needs: *

By signing below, I attest that the information I have provided is accurate. I am requesting the amount that I need and acknowledge that there are limited funds available for families requiring assistance. *

Signature

Today's Date:

Print Name:

Relationship to Student:

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Scholarship Request Form