Youth Program Scholarship Application

Application for Scholarships

Chintimini Wildlife Center Youth Education Programs
Child's Information
Child's Name *

First Name Last Name
Age *
Which program is your child interested in?
Parent/Guardian Information

Please fill out this section completely.
Parent/Guardian's Name *

First Name Last Name
Phone Number

Area Code Phone Number
Email *
example@example.com
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Financial Information

Fill out the corresponding sections that best describes your situation.
Number of Adults in Household *
Number of Children in Household *
Ages of Children *
Does your child qualify for free or reduced meals? *

Free meals Reduced meals Does not qualify
Total Household Income:

Please detail your monthly income below.
Wages
TNAF
SSI
Child Support
Oregon Trail Benefits
Total Household Income per month *
Have you received a scholarship from us before? *

Yes No
Please provide copies of all your income so that we may determine if you qualify. If you receive Oregon Trail benefits, you only need to provide a printout that shows the income that you reported to the State and the amount they awarded you in cash and/or food assistance. You can obtain this printout at the front desk of your local Department of Human Services (DHS) office.
Proof of Income

Upload File or Photos

Cancel of
We offer 50% scholarships and a limited number of 100% scholarships. Which scholarship would best reflect your family's needs? *

Partial scholarship (50%) Full scholarship (100%)
Other Circumstances

In the space provided below, please describe any other reasons or circumstances (past, present, or future) that you feel increase your qualification and/or need for financial assistance at Chintimini Wildlife Center (e.g., family circumstances, academic standing, etc).
Reason or Circumstance:
Signature:

I certify that the above information is accurate and completed to the best of my knowledge. I give Chintimini Wildlife Center permission to verify all of the above information. I understand that any incorrect information will result in the immediate disqualification for the requested discount.

Conditions:

The program fee (minus the 50% scholarship) is the amount you owe for the program. This fee must be paid in full on or before the first day of your child's program.
Parent/Guardian Signature *
Date

Day Month Year
Should be Empty:

Application for Scholarships

Child's Information

Parent/Guardian Information

Financial Information

Other Circumstances