Hardship Youth Scholarship

Parent/Guardian Name (required)

Address (required)

City (required)

Zip Code (required)

Email (required)

Primary Phone (required)

Secondary Phone

Child's Name (required)

Child's Date of Birth (required)

Child's Grade (required)

Child's School (required)

Hardship Scholarship Qualification - Please mark which hardship category best describes what your family is experiencing (required)

Recent loss of employment, reduction in work hours, furlough, or significant decrease in household income.

Unexpected medical expenses for a child or household member.

Death of a parent, guardian, or primary income earner.

Divorce, separation, or another significant change in family circumstances.

Homelessness, temporary housing, housing instability, or risk of eviction.

Foster youth placement, kinship care, or guardianship arrangements.

Natural disaster, fire, flood, or other emergency situation.

None of the apply

If none of these hardship catagories describes your situation, or you are uncomfortable answering the question, please provide an explanation to help CRPD staff determine eligibility.

Program Registration - Please provide us which program you would like to receive a partial scholarship for. (required)

Participant Contribution - Upon application approval, you will be required to register your child and provide a partial payment. The Hardship Scholarship covers 30% of the program fees. The participant contribution would be 70% of the registration fees. Do you understand and agree to these terms? (required)

Yes

No

Please read the following statement and provide your answer: I declare that the information contained in this form is correct and complete. I will be responsible for the payment of the adjusted fee. I understand that any scholarship awarded will be revoked in the event of misrepresentation, or by failing to follow all the terms as agreed to. I understand that supporting documentation may be requested when appropriate by CRPD staff. I further understand that if the scholarship is revoked and services have been rendered, the full amount of fees will be my sole responsibility. (required)

Yes

No

Hardship Youth Scholarship Application

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