Boys & Girls Club Scholarship Form

Boys & Girls Club Scholarship Form

Please be advised that scholarship funds are limited. Scholarships are awarded on a case-by-case basis.
Parent/Guardian Name

First Name Last Name
Employer
Household Annual Income
ALL income in the household regardless of relation to child.
Household Size
All Adults and Children residing in the household regardless of relation to child.
Email
example@example.com
Phone Number

Area Code Phone Number
Which Club will your child(ren) attend?

Fort Mohave Bullhead Laughlin
Name & age of Child
School
Name & age of Child
School
Name & age of Child
School
Is the above named child(ren):

In your care as a foster child Being raised in a single parent household Being raised by non parent relatives (grandparent, aunt etc.) Eligible & receiving SNAP benefits Receiving other government aid
Please explain why your child(ren) should be considered for scholarship assistance:
Please attach most recent pay-stub for ALL adults in the household

Browse Files

Cancel of
Which Program are you applying for:

After School Program Fridays Only Summer Day Camp
By signing below, I acknowledge that the income and household size is true and correct. I understand that scholarships may be revoked at any time for any reason. I acknowledge that monthly membership fees are due at the beginning of each month. Failure to stay current on my account may result in my scholarship being revoked. I understand that scholarships are only good for the monthly fees and will not apply to "Drop Days" or "Weekly Fees" or the $10.00 membership fee. I understand that the scholarship is only valid for the program I am applying for (i.e., afterschool or summer). I understand that I must reapply at the end of each session if I still need financial assistance.

I agree I disagree
Signature

Clear
Should be Empty: