Scholarship Request Form - Kerrville

Scholarship Program Instruction Sheet
Please read carefully and follow the step-by step instructions to complete your scholarship application.
1. This packet includes the Scholarship Program Agreement Form and the Scholarship Request Form.
2. Please read the Scholarship Program Agreement Form, sign and date at the bottom of the page.
3. Completely fill out the Scholarship Request Form. Scholarship Applications are accepted on a quarterly basis
according to this schedule.
Acceptance of Applications
Processing Period
Membership Term
March 1–14
March 15-30
April – March (1 yr.)
June 1–15
June 16-30
July – June (1 yr.)
Sept. 1–15
Sept. 16-30
Oct. – Sept. (1 yr.)
Dec. 1-15
Dec. 16-31
Jan. – Dec. (1yr.)
4. Summer Camp Scholarship Applications are accepted once a year. This year’s deadline is May 7, 2012 for
Summer Camp Scholarship Applications. Please use this same form for Camp Scholarship requests. The
registration date for camps will be found in our Summer Camp guide. Issuance of a camp scholarship does not
guarantee placement in the camp. Placement is based upon the date of enrollment and space availability.
5. Attach all copies of income verification to the application. Acceptable forms of proof are listed on the next
page.
6. Mail the completed information, which includes the signed Scholarship Agreement Form, the Scholarship
Request Form and copies of support materials to:
TSA Kroc Center
Attn: Scholarship Committee
Or you may deliver your application in a sealed
P.O. Box 290790
envelope at the Kroc Welcome Center.
Kerrville, TX 78029-0790
7.
You will be notified of your scholarship opportunity by mail.
8. When you receive your scholarship verification from the Kroc Center, please bring your confirmation letter to
the Kroc Center. You must have this letter with you to register for Kroc Membership, Summer Camps or
Programs. You enroll with the first month of the new period that starts after your award letter is granted
(January, April, July or October). After that date our offer will be considered void.
9. When you come in to sign up, the Welcome Center Staff will complete your membership, camp or program
information, accept your payment and in the case of membership, take your picture and issue your
membership card.
Thank you! We look forward to seeing you soon!
Scholarship Program Agreement Form
Kroc Center Scholarship Program
The Salvation Army Kroc Center is pleased to provide a comprehensive scholarship program to help provide access to this facility.
It was Joan Kroc’s vision and expectation that all individuals have equal opportunities to grow their natural gifts and talents. The
Kroc Center is a world-class facility allowing just that; an equal opportunity which allows each person the chance to discover and
develop their natural gifts. We are delighted that you are interested in participating.
Please read carefully
1. Please complete the attached application and provide copies of proof of income (acceptable proof: 2 current pay stubs,
TANF notice, child support, Social Security, SNAP Letter, Unemployment statements, Federal Tax return, etc.). Submit
completed application and paperwork to the address mentioned on the Instruction sheet by the deadline for the
upcoming scholarship period. Incomplete applications will be returned. Any information found to be fraudulent will
result in loss or denial of the scholarship award.
2.
Completion of the application does not guarantee assistance. Scholarships will be awarded based on eligibility, funding,
timeliness, and space available.
3.
All requests will be responded to by mail. Once approved, the applicant is invited to return to the Center to complete
membership, camp or program enrollment within the first month of the new period (January, April, October or
December). Award recipients that do not respond within this first month will not be eligible to use the scholarship.
4.
Membership payment may be made in one of the following ways; automatic monthly withdrawal through your checking,
savings, or credit card account; or monthly cash installments. Please be prepared to pay your first installment at
registration. Should you lapse on your payment schedule we reserve the fight to terminate the scholarship award.
5.
Registration fees cannot be waived.
6.
Scholarship recipients are expected to financially contribute toward the membership. Recipients will be asked to provide
25%, 50%, or 75% of the Membership based on financial capability.
7.
Membership Scholarship recipients will be eligible for a 50% reduced rate on all classes and programs which have an
additional fee during their award period.
8.
There is no scholarship benefit for activities that fall outside of the membership, Summer Camps, Programs or classes
(such as food at the concession or merchandise, etc.).
9.
All scholarship recipients will be eligible for a 25%, 50%, or 75% discount for Summer Camps. Also, applicants may apply
for only a camp scholarship if desired. The summer camp application deadline is May 7, 2012. The camp scholarship
does not cover activities outside of the camp. Issuance of a camp scholarship does not guarantee placement in the camp.
Placement is based upon date of enrollment and space availability.
10. Non-Use of your Kroc Center membership may result in discontinued scholarship assistance. Programs, classes, and
camps for those who have received scholarship support must be attended by the recipient. Future requests by the same
applicant may not be considered if funds for programs are misused.
11. Scholarships are valid for 12 months from approval. Re-applying will be required at the end of the scholarship period
and continued use will be dependent upon financial information and the frequency of previous use at the Kroc Center.
12. All Scholarships are confidential. Applicants agree to refrain from discussing awards with others.
13. Please sign as verification of your understanding and acceptance of the Kroc Center Scholarship Program.
Signature______________________________________________________
Print Name____________________________________________________
Date____________________________________
Scholarship Request Form Solicitud para beca
Check Appropriate Box:
Membership Application
Program Application
Summer Camp Application
Seleccione uno de los cuadros: Solicitud de membrecia
Solicitud para programa
Solicitud para campamento de verano
SECTION I – APPLICANT INFORMATION (INFORMACION DEL APLICANTE)
Last Name (Apellido): __________________________________ First Name (Nombre):_____________________________________
Address (Direccion): ___________________________________________________ City (Ciudad): ___________________________
Zip Code (Codigo Postal):_____________ Home Phone (Telefono del la casa): ________________ Cell(celular): ________________
Work Phone (Trabajo)______________________ email_____________________________________________________________
License ID # (Licencia de Manejar): _________________________ SS# (Seguro Social):_____________________________________
Birthdate (Fecha de Nacimiento): ______________________________ Marital Status (EstadoCivil): S /S M/C
D/D O/O
SECTION II – OTHER HOUSEHOLD MEMBERS (OTROS MIEMBROS DE LA CASA)
List all persons living in household with applicant. Please indicate if children are foster children. (Escriba los nombres de todas las
personas que viven en su casa. Indique si los niños que viven con usted son adoptados).
Name
Age
Sex
Relationship to Applicant
Social Security #
Birthdate
(Nombre)
(Edad) (Sexo)
(Relacion con el Aplicante)
(Seguro social)
(Fecha de nacimiento)
SECTION III – HOUSEHOLD FINANCES (INGRESOS FINANCIEROS DE LA CASA)
Total Household Income per month for ALL PERSONS living with applicant (Ingresos mensuales de TODAS LAS PERSONAS en la casa):$__________
Include cash payments for “odd jobs”. Mark Sources of Income/Aid (Incluya pagos en efectivo por”otros trabajos”Formas de ingreso/ayudas):
Gross Salary from your Job (Ingresos total)$________________ Occupation (Ocupacion): _________________________________________
SSI/SSA (Seguro social)$_________________________ Child Support/Alimony (Manutencion de menores)$________________________
Disability (Por desabilitacion)$_________________ TANF$_________________ SNAP benefits (Estampillas)$ ____________________
Other, please list (Otros): $____________________________________
REASON FOR REQUEST: (PLEASE LIST ANY SPECIAL CIRCUMSTANCES YOU WOULD LIKE US TO KNOW- ATTACH LETTER IF NEEDED)
RAZON DE APLICACION: (POR FAVOR INCLUYA CIRCUMSTANCIAS ESPECIALES QUE A USTED LE GUSTARIA QUE CONSIDEREMOS.
INCLUYA UNA CARTA SI ES NESECARIO)__________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
This application and required income documentation are confidential information and will be used only for scholarship
recommendations by the Membership Supervisor. (Esta aplicacion y los documentos de ingresos requeridos son información
confidencial y solamente serán usados para la revision de becas por el supervisor de membrecía).
NOTICE - in order to promote a safe and secure environment, The Salvation Army Kroc Center has placed video cameras in various
locations. As part of our commitment to the safety of children and vulnerable persons, The Salvation Army Kroc Center reserves
the right to consult public sources to determine whether any member or guest of any member poses an unreasonable risk of harm
to its patrons, staff, or visitors. (Nota – para poder promover un ambiente seguro y confiable, El Kroc Center del Salvation Army a
puesto cámaras de seguridad en varias áreas. Como parte de nuestro compromiso para la seguridad de los niños y personas
vulnerables, El Kroc Center del Salvation Army se reserva el derecho a consultar con fuentes públicas para determinar si algún
miembro o visitante esta en riesgo de dañar sin razón alguna a sus patrones, empleados, o visitantes).
SIGNATURE (FIRMA):
DATE (FECHA):
FOR OFFICE USE ONLY (PARA USO DE LA OFICINA SOLAMENTE):
DATE RECEIVED: RECEIVED BY:
PERCENTAGE TO BE PAID BY PARTICIPANT____________ PERCENTAGE TO BE PAID BY KROC___________APPROVED YES
NO DATE ____________
Notes:__________________________________________________________________________________________________
________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
_________________________
THE SALVATION ARMY
2012 SCHOLARSHIP APPLICATION
______________________________________________
Last Name
First Name
______________________________________________
Address
________________________
Phone #
______________
City
_____ ______
St
Zip
List all individuals in the household
Last Name
MONTHLY INCOME
SOURCE
Husband Employment
Wife Employment
Other Employment
TANF
Disability
Social Security
SSI
Child Support
Food Stamps
Other Income
TOTAL INCOME
First Name
AMOUNT
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
Age
Sex
Relationship
Applicant
MONTHLY EXPENSE
SOURCE
AMOUNT
Rent/Morgtage
______________
Utilities
______________
Groceries
______________
Insurance
______________
Car
______________
Furniture
______________
Loans
______________
Telephone
______________
Cable
______________
Other Expenses
______________
TOTAL EXPENSES ______________
COMMENTS:
____________________________________________________________________
_________________________________________________________________________________
I certify that all information contained in this application is complete and accurate. I understand
that giving false information could result in my application being denied. I also understand that by
completing this application I am not guaranteed a scholarship.
Signature
*Please be sure this application is filled out completely and accurately. Proof of all household
income must accompany this form. Applications with missing documentation or incomplete
information will not be considered.