HOPE TRC Scholarship Application

P.O. Box 242. Rochester. IL. 62563 217-816-8802 www.findinghoperiding.org

HOPE TRC Scholarship Application ______Date of application: ______/______/______Participant Information STATUS: __ New Client __ Current Client __ Current Scholarship Recipient (if known) Name: ______Home Address: ______City: ______State: ______Zip: ______Phone: ______Email: ______

Individual Completing Scholarship Application: Name: ______Relationship to Scholarship Nominee: ______Phone: ______Email: ______

Questions Regarding SCHOLARSHIP AWARD Scholarship assistance may be partial or 100% funded if awarded. Is this request for FULL or PARTIAL assistance? __ Full __ Partial

Financial Need ESTIMATED ANNUAL GROSS INCOME FROM ALL SOURCES: __ Up to $15,000 __ $15,000 - $30,000 __ $30,000 - $50,000 __ $50,000 - $75000 __ Above $75,000 Number of Dependents in Household: _____ Adults _____ Children _____ Other Are any other members in the household disabled? __ Yes __ No Does the participant enrolled in any federal, state or local programs that aids students from low-income families? __ Yes __ No

Economic Need Does the participant receive FREE or REDUCED priced school lunches? __ Yes __ No Does the participant receive __ TANF __ SNAP __ Medical Benefits __ No Does the participant live in federally funded housing, a foster home, or is homeless? __ Yes __ No Is the participant in foster care? __ Yes __ No Hardship Need Do you believe that the fee would create a financial hardship? __ Yes __ NO If yes, please provide a brief explanation about why you are applying for scholarship assistance. The background of the participant’s circumstances/situation will help the director make a decision. Include any details you are comfortable sharing to best support your reasons. You may attach a separate sheet if needed or write on the back. ______

I, hereby state, to the best of my knowledge all of the answers provided on this form are true and accurate of the participant’s current situation.

Signature: ______Date: ______

SUBMIT THIS APPLICATION TO: (for purposes of privacy, please do NOT email) HOPE Therapeutic Riding Center Attn: Scholarships P. O. Box 242 Rochester, IL 62563