WAKEMAN BOYS & GIRLS CLUB SCHOLARSHIP REQUEST FORM

Child’s Name:__________________________________________________________________

Address:______________________________________________________________________

City:_____________________                      State:______________            Zip:______________

Phone:_________________              Email Address:___________________________________

Age:____            Date of Birth:________             School:__________________          Grade:_______

How long has child been a club member?:________

Parents Information:

Mother’s Name:___________________      Place of Employment:________________________

Father’s Name:____________________     Place of Employment:_________________________

____ Married               _____ Separated            ______ Divorced

Annual Family Income:________________

Are you receiving other financial assistance?                 ______ Yes            ______ No

If yes please explain:

Total # Adults Living in Household:_______        Total # Children Living in Household:_______

Program Information:

Programs you wish to participate in:________________________________________________

Are you receiving any money towards Wakeman fees from other sources?  _____Yes  _____No

_________________________________                                          ________________________

Parents Signature                                                                                  Date

Please fill out this form in full.  Failure to do so will result in a delay in processing the form.

Any false information can result in your denial for assistance.

Office Use Only:            Accepted______________                Denied_____________