ELIGIBILITY AND APPLICATION REQUIREMENTS

Transcription

1 ELIGIBILITY AND APPLICATION REQUIREMENTS BASIC ELIGIBILITY REQUIREMENTS At least 16, but nt mre than 25 years ld at the time f applicatin Dependent f Indiana wrker fatally r catastrphically injured as a result f a wrk related accident r ccupatinal disease The qualifying injury/illness/death must have ccurred as a result f wrk activities perfrmed n behalf f an Indiana emplyer; althugh, neither the student applicant nr the deceased/injured wrker are required t be a legal resident f the State f Indiana The qualifying injury/illness/death must be cmpensable as stated by the Wrkers Cmpensatin Bard f Indiana (WCB) The qualifying injury/illness r death must have resulted in a substantial decline in the family s incme Enrlled as student (full-time minimum f 12 hurs; part-time minimum f 6 hurs) in the fllwing types f institutins: High Schl Trade Schl/Vcatinal Schl/Industrial/Cmmercial Training Junir Cllege/Cmmunity Cllege Cllege-Undergraduate r Graduate Schl 1

2 COMPLETE APPLICATION PACKAGE CHECKLIST Cmpleted Kids Chance f Indiana schlarship applicatin. Mst current academic transcript (unfficial transcripts are accepted). Cpy f last tw (2) year s Federal tax returns f applicant and his/her parent(s) and/r legal guardian. Cpy f Student Aid Reprt (SAR) frm FAFSA stating the Expected Family Cntributin. Cpy f the injured parent s First Reprt f Injury n file with the WCB. Mst recent case manager and/r physician reprt describing the present medical status f the injured parent (if applicable). Death Certificate fr a deceased parent (if applicable). Brief written descriptin f the accident and resulting injuries. Bigraphy frm the applicant t include descriptins f their educatinal gals and hw Kids Chance can help them achieve success. ( wrds) Letter(s) f recmmendatin (ptinal). Recent digital phtgraph f applicant. (Label and pht: (tcriden@criden.cm) PLEASE SUBMIT COMPLETED APPLICATION AND SUPPORTING DOCUMENTS BY JUNE 1, YEAR OF APPLICATION. KIDS CHANCE OF INDIANA th St., P. O. Bx 1510 Clumbus, IN P /F *The pririty date fr filing fr federal financial aid is March 1 prir t the academic year. The frm, Free Applicatin fr Federal Student Aid (FAFSA) is available n-line r thrugh the schl s guidance ffice. Upn filing the FAFSA, the applicant will receive a Student Aid Reprt (SAR) frm the Federal Student Aid Prgram. After the first year f higher educatin, the applicant is required t prepare and file the Renewal Free Applicatin fr Federal Student Aid (Renewal FAFSA). We request cpies f the FAFSA and SAR fr each academic year as supprting dcumentatin fr the schlarship applicatin. Please nte the frms, addresses and dates abve are nt gverned by Kids Chance f Indiana and may be subject t change. It is the respnsibility f the applicant t cmply with all applicable regulatins f federal and state agencies as well as thse f the educatinal institutin where the student plans t attend. 2

3 NEW Schlarship Applicatin DEADLINE IS JUNE 1 st, YEAR OF APPLICATION Sectin A: STUDENT APPLICANT INFORMATION Name: First Middle Last Present Address: Address City State Zip Cunty Phne: Alternate Phne: Age: Date f Birth: / / Scial Security #: - - 3

4 Sectin B: SURVIVING FAMILY INFORMATION Father s Name: Mther s Name: Parent s Address: Address (if different than abve) City State Zip Cunty Phne: # Residing in Husehld: Less than 18 years ld: Parent s Is this parent emplyed? Y N If YES, Full-time Part-time If YES, Name f Emplyer: Emplyer Phne: 4

5 Sectin C: INJURED/DECEASED PARENT INFORMATION Parent s Name: First Last Relatinship: Scial Security #: - - Date f Injury r death: / / Emplyer f Recrd (when accident/injury/illness/death ccurred: Address: City: State: Zip: Emplyer Phne: If INJURED, is the parent currently emplyed? Y N If YES, Full-time Part-time Wrker s Cmpensatin Bard Accident r Applicatin Number: DESCRIPTION f ACCIDENT & RESULTING INJURIES: attach additinal pages if needed 5

6 SECTION D: ACADEMIC INFORMATION Applicant s High Schl Infrmatin High Schl Attended/Attends Schl s Address City/Twn State Zip Cde: Telephne Number GPA: Educatinal Institutin fr Which Applicant Intends t Use Schlarship Name f Institutin Schl s Address City/Twn State Zip Cde: Have yu already been accepted by this institutin? Yes N Date yu will be starting/cntinuing educatin at this institutin is: (MM/YYYY) Type f educatinal institutin: (Pick nly ne): High Schl Trade Schl Junir Cllege/Cmmunity Cllege Industrial/Cmmercial Technical Cllege Cllege (Undergraduate) Graduate Schl (specify Type) Other (specify) Majr Field f Study: Career Objectives: What year d yu expect t graduate? Estimated Annual Tuitin: $ 6

7 SECTION E: FINANCIAL AFFIDAVIT Please nte that in additin t prviding the financial infrmatin t fllw in this applicatin, any applicant wh will be using Kid s Chance Schlarship Grants fr cllege r technical/trade schl educatinal purpses (i.e. pst high schl educatin) shuld append his/her Free Applicatin fr Federal Student Aid (FAFSA) and Student Aid Reprt (SAR) dcuments with their applicatin. Current Family Incme (Mnthly Average) Wrker s cmpensatin benefits... $ Disability insurance... $ Other insurance payments... $ Incme per mnth f spuse f injured/deceased emplyee... $ Name & address f spuse s emplyer Additinal incme f ther dependents f injured r deceased emplyee residing in same husehld with applicant. Please identify surce and amunt. Student Applicant... $ Dependent1:... $ Dependent 2:... $ Dependent 3:... $ Dependent 4:... $ Financial assistance frm any state r federal agency... $ Child supprt payments received n behalf f children residing in the husehld with applicant... $ Interest/dividend/annuity incme... $ Other incme. Please identify surce and amunt. Surce Amunt $ Surce Amunt $ Ttal Mnthly Incme... $ Please explain in detail any anticipated future changes in average mnthly incme: Current Family Expenses (mnthly average) Rent r mrtgage payment... $ Fd... $ Clthing... $ 7

8 Incidentals... $ Medical/dental bills (nt cvered by wrker s cmpensatin)... $ Car payments... $ Maintenance fr cars, including gas & il... $ Recreatin... $ Health insurance payments... $ Autmbile insurance... $ Hmewner s/renter s/casualty insurance... $ Taxes-prperty... $ Taxes-ther... $ Electric utility bill... $ Gas utility bill... $ Telephne bill... $ Water/sewer bill... $ Child supprt payments made t children nt residing in applicant s husehld... $ Any ther mnthly expenses (please specify) Item 1 $ Item 2 $ Item 3 $ Ttal Mnthly Expenses... $ Please explain in detail any anticipated future changes in average mnthly expenses: Current Family Assets Cash n hand r in banks (saving, checking, etc)... $ Stcks, bnds, ntes... $ Real estate-hme... $ Other real estate... $ Autmbiles... $ Other vehicles (e.g. bats, snwmbiles, etc)... $ Other assets, please itemize: Asset 1 $ Asset 2 $ Asset 3 $ 8

9 Ttal family assets... $ Current Family Liabilities Credit unin... $ Real estate mrtgage... $ Autmbile lans... $ Other ntes/lans/debt (please specify) Debt 1 $ Debt 2 $ Debt 3 $ Ttal family liabilities... $ Is any family member currently a plaintiff/claimant in a lawsuit frm which additinal incme r a settlement may be awarded? Yes N If yes, please explain: Please identify all ther schlarships and financial aid fr which yu have applied. Have yu been awarded any ther schlarships r financial aid? Yes N If yes, please identify all awards by surce and amunt and include all FAFSA and SAR dcuments with yur submissin t KCIN. Award Amunt $ Award Amunt $ Award Amunt $ Please detail any unusual r extenuating circumstances which yu feel shuld be cnsidered in prcessing yur applicatin. Hw did yu learn abut the Kids Chance f Indiana Schlarship prgram? 9

10 SECTION F: STUDENT EXPECTATIONS The missin f Kids Chance f Indiana, Inc. is t prvide educatinal schlarships t the children f Indiana wrkers wh have been seriusly, catastrphically r fatally injured in wrk---related accidents. All applicatins are subject t review f the Schlarship Cmmittee and all schlarship awards are cntingent upn availability f funds. Schlarship recipients expectatins: Cmmunicate prmptly t Kids Chance bard as requested Maintain at least a 2.0 cumulative grade pint average Students must be registered fr at least hurs each semester; unless therwise apprved. Ntificatin f drpped classes at the time yu withdraw, nt at the end f the semester. At the end f each semester, students are required t send in grades fr the current term and their schedule fr the upcming term t be cnsidered fr further funding. Kids Chance requires each student attend ONE fundraising functin/effrt each calendar year. This may include special events, testimnials, etc. 10

11 SECTION G: AUTHORIZATION STATEMENT I CERTIFY THAT ALL OF THE INFORMATION PROVIDED IN THIS APPLICATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF. Signature f Applicant Date Signature f Parent Date I understand that schlarships granted by Kids Chance f Indiana are benevlent awards that are made n the basis f the funds available t the Kids Chance f Indiana rganizatin and upn the quantity and quality f applicatins each year. I understand that schlarship decisins are made by the Kids Chnace f Indiana s Schlarship Cmmittee and its Bard f Directrs, and that they have discretin f the number and amunt f awards. I understand and agree that all schlarship award prceeds must and will be used fr higher educatin tuitin, fees, bks, rm and bard, and utilities nly. I understand that I must verify my nging successful academic perfrmance during the curse f each grant year and that I have an affirmative bligatin t advise Kids Chance f Indiana f any change in circumstances which may affect further schlarship eligibility. I understand that this schlarship is fr ne academic semester nly an that I am required t re-apply each semester per the stated deadlines fr any subsequent schlarship cnsideratin. I hereby authrize and give cnsent t Kids Chance f Indiana and Kids Chance f America, their directrs, trustees, fficers, agents, emplyees, and/r designees t use my name and likeness in their prmtinal materials, including but nt limited t, printed materials, their websites, and electrnic media. I further cnsent t and authrize Kids Chance f Indiana and Kids Chance f America t ntify varius media (including lcal newspaper, Televisin, radi and nline news utlets) f the award f a schlarship t me, as well as ther infrmatin cncerning such an award including but nt limited t: bigraphical infrmatin, descriptin f educatinal gals, and the wrk injury incident infrmatin. It is the plicy f Kids Chance f Indiana t safeguard persnal, health, emplyment and financial infrmatin therwise. Kids Chance des nt sell cntact infrmatin r share infrmatin with utside rganizatins r agencies. Kids Chance Inc. f Indiana is cmmitted t imprving the educatinal chices f children whse families have been financially impacted by a wrkplace injury r death. As a vlunteer-driven nnprfit rganizatin, Kids Chance f Indiana prvides schlarships t children f Indiana wrkers wh have been seriusly r fatally injury in a wrk-related accident r illness that has resulted in financial need. Each year, Kids Chance makes a significant difference in the lives f these families by prviding schlarship supprt t help eligible students pursue and achieve their higher educatin gals. 11

12 Schlarships are awarded semi-annually in alignment with the academic year t applicants based n, but nt limited t, academic perfrmance, need and available funds. Kids Chance f Indiana is part f Kids Chance f America and jins 30 ther state rganizatins in delivering the Kids Chance missin. Signature f Applicant Date Signature f Parent Date Please submit yur cmpleted applicatin t Kids Chance f Indiana. Please include all required supprtive dcumentatin requested. Yu may yur applicatin with dcumentatin attached t tcriden@criden.cm r mail it t: Terry Criden, Attrney 445 5th St., P. O. Bx 1510 Clumbus, IN Kids Chance f Indiana, Inc. If yu have any questins r need assistance cmpleting yur applicatin, please cntact Mr. Criden (812)