Date
Name of Child
First Middle Last
Previous Name(s)
DOB (mm/dd/yyyy) M/F SSN
PREV SSN
Name of
Legal Guardian
Address
City State AZ Zip
Phone
Alternate Phone
Email
Return completed form to:
Name of STO
Contact Name FAX number
Email
VERIFICATION (to be completed by DCS)
Student QUALIFIES for the Displaced Scholarship program in accordance with A.R.S. 43-1505
Student DOES NOT QUALIFY for the Displaced Student Scholarship program due to the following:
There is no indication that the child was in foster care in Arizona pursuant to A.R.S. Title 8, Chapter 4.
Other (explain):
DCS Verification - Signature
Date
Displaced Student Applicant Form
TOPS for Kids
Harry Miller
harry@topsforkids.com
1-888-256-1130
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