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2017 Scholarship Application

Scholarship Application

All information provided will be held strictly confidential and will not be used for any other purpose.
False information will result in your being disqualified for a scholarship.

Please submit your completed application and included ONE of the criteria listed:

- Written documentation of participation in programs such as: Food Stamps, Medicaid, SSI, Foster Care, WIC. etc. OR
- Written recommendation by school representatives, social workers, youth community center works, or other social services representatives. OR
- Documentation demonstrating an immediate financial hardship (copy of disability payment). OR
- Copy of recent tax forms (please block out pertinent personal information)

The Harlyesville Youth Association (HEYA) does not discriminate based on gender, race, class, economic status, ethnic background, sexual orientation, physical ability, or cultural and religious backgrounds.

* Today's Date:

PLAYER'S INFORMATION

* Last Name:

* First Name:

* Birth Date:

Other sports/activities/clubs your player is involved with::

* Program you are applying for:

Cheer

Flag Football

Tackle Football

FAMILY INFORMATION

* Your Last Name:

* Your First Name:

* Relationship to Applicant:

Parent

Guardian

Head of Household

* Address:

* Phone Number:

Email Address:

* Has your child ever played with The Harleysville Eagles before?:

Yes

* Have you enrolled in our scholarship program in the past?:

Yes

* Do you receive?:

* Is Social Security income your family's only source of income?:

Yes

* What is your family annual gross income (before expenses and taxes)? $:

* How many individuals in your family (including yourself) are supported by your income?:

Please complete the following for each parent/guardian. Place a zero (0) in the area that does not pertain to you. If you are the sole financial provider for your child, please enter zeros (0) in the Parent/Guardian (2) sections.

PARENT/GUARDIAN (1)-Monthly Income

* Net Income from Self-employment $:

* Social Security $:

* Public Assistance/Welfare $:

* Unemployment/Disability $:

* Worker's Compensation $:

* Alimony and/or Child Support $:

* Other (rentals, royalites, etc) $:

* Total for Parent/Guardian (1) $:

PARENT/GUARDIAN (2)-Monthly Income

* Net Income from Self-employment $:

* Social Security $:

* Public Assistance/Welfare $:

* Unemployment/Disability $:

* Worker's Compensation $:

* Alimony and/or Child Support $:

* Other (rentals, royalites, etc) $:

* Total for Parent/Guardian (2):

* TOTAL OF BOTH PARENTS $:

I verify that the above information is correct. *

* If a partial scholarship were available, how much can you afford to pay?:

* Please state the circumstances and provide any explanation or information that you feel will be useful in our determination.:

REQUIREMENTS FOR ELIGIBILITY

1. Commitment to attend a minimum of 90% of scheduled practices, training and games.

2. Participation by an adult family member in at least 10 hours of voluntary service to HEYA during the season that runs August through November.

I have read the requirements for eligibilty and understand what is required of my child and myself. *

NOTE: SCHOLARSHIPS ARE NOT AVAILABLE FOR EVERYONE. THE AMOUNT OF SCHOLARSHIP AWARDED (IF ANY) MAY BE A PARTIAL OR FULL SCHOLARSHIP DEPENDING ON THE NUMBER OF APPLICANTS AND THE AMOUNT OF SCHOLARSHIP FUNDS AVAILABLE.

Applications should be submitted as soon as possible and no later than June 1st, 2014.

By electronically submitting this application I understand this represents my signature for application. *

Signature:

Date:

* indicates required fields

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The Harleysville Eagles Youth Association is a 501c3 tax-exempt organization.

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2017 Scholarship Application