THERMAN GRAY
SCHOLARSHIP
APPLICATION
NAME OF
PARTICIPANT: DATE:
NAME OF
PARENT/GUARDIAN:
ADDRESS:
PHONE NUMBER:
ALTERNATE
PHONE
NUMBER:
ACTIVITY BEING APPLIED FOR
(title
and number):
ELIGIBILTY
REQUIREMENT
(check all that
apply
and
attach proof of eligibility):
SUPPLEMENTAL SECURITY INCOME (SSI)
SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP)
TEMPORARY ASSISTANCE FOR NEEDY FAMILIES (TANF)
SPECIAL SUPPLEMENTAL NUTRITION PROGRAM FOR WOMEN,
INFANTS, AND CHILDREN (WIC)
FREE OR REDUCED PRICE LUNCH
OTHER
EXPLANATION:
*I attest
that the
information
that I have provided is true and
accurate
to
the best
of my knowledge.
Providing
inaccurate
information
will
lead
to disqualification
of scholarship funds.
SIGNATURE: DATE:
For
more information and
complete
details,
call
(410) 535-1600 ext. 2649.
Calvert
County Services
are
accessible
to individuals with disabilities.
For the hearing and speech impaired
call
(800)
735-2258
.
EMAIL ADDRESS:
Office Use Only:
Household Name:__________________________HH#__________ Approved by_____________Amount $_____________
Activity #________,_________,_________,__________,_________,__________ Date Applied:____________Date Entered:_____________
PARTICIPANT DATE OF BIRTH:
click to sign
signature
click to edit
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