Fillable Scholarship-kids-camps Kids on Campus Scholarship Request Form

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Scholarship-kids-camps Kids on Campus Scholarship Request Form

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HUDSON VALLEY COMMUNITY COLLEGE
KIDS ON CAMPUS SUMMER/VACATION PROGRAMS
SCHOLARSHIP REQUEST FORM
Child’s Name __________________________________Child’s SS# ___________________________
Child’s Age ____ D.O.B.____________ Grade ______ School _______________________________
Child’s Address______________________________________________________________________
Parent/Guardian______________________________________________________________________
Telephone (Day) _____________________________ (Evening) _______________________________
DETERMINATION OF INCOME ELIGIBILITY GUIDELINES
Use the chart below to determine if you are eligible for a scholarship and circle appropriate household size
Please submit a copy of your 2018 Income Tax Return or a paystub along with this form.
HOUSEHOLD SIZE
INCOME
Year
Month
Week
1
22,459
1,872
432
2
30,451
2,538
586
3
38,443
3,204
740
4
46,435
3,870
893
5
54,427
4,536
1,047
6
62,419
5,202
1,201
7
70,411
5,868
1,355
8
78,403
6,534
1,508
For each additional
family member add
+7,992 +666 +154
What is your household size? _______
* If your income exceeds the amount listed for your household size please send in your request anyway. If we have
additional funds to award we may extend the eligibility requirements.
REFERRED BY:
Name: ____________________________________ Phone: ___________________
Agency: ___________________________________ Date: ____________________
Additional information that you feel should be considered in determining need:
PLEASE RETURN TO:
Hudson Valley Community College
Office of Community Education
80 Vandenburgh Avenue
Troy, NY 12180
Phone (518) 629-7339 Fax (518) 629-8103
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Scholarship-kids-camps Kids on Campus Scholarship Request Form

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Completed 4 December 2019

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