P. O. Box 681383 www.kidschanceoftn.org Franklin, Tennessee 37068-1383 info@kidschanceoftn.org Scholarship Application Student Applicant Information (first) (middle) (last) Present Address: (address) (apt. no.) (city) (state) (zip) (county) Telephone: ( ) ( ) (home) (mobile) (email) Date of Birth: / / Social Security Number: - - High School Attended: (address) (city) (state) (zip) Institution you plan to attend: (address) (state) (zip) Have you been accepted by this institution? YES _ NO _ Additional institutions you have applied to and are you accepted? What month and year will you begin studies at this institution? For what other scholarships or financial aid have you applied?
Have you been awarded any scholarship or financial aid? (name of award) (name of award) $ (amount) $ (amount) What is your major field of intended study? What are your career objectives? _ What other information would you like to provide that would affect our review of your scholarship request? How did you learn about Kids Chance? Are you or anyone in your household involved in litigation of any kind? If yes, please explain: Injured/Deceased Parent Information Name of parent and relationship: (first) (middle) (last) (relationship) Address, phone, email: Social Security Number: - - Date of Injury/Death: / / Employer at the time of injury/death: (phone number) (address) (state) (zip) Please provide a description of the accident and resulting injuries:
Family Information Mother s Name: _ Address: Telephone: ( ) ( )_ (home) (mobile) (email) Father s Name: _ Address: Telephone: ( ) ( ) (home) (mobile) (email) Employer for spouse of injured/deceased: _ (name and address) How many dependent family members reside at the same home as the applicant? Financial Information Source of Income: Monthly Average 1. Workers Compensation $ _ 2. Disability Insurance, including SSDI $ _ 3. Other Insurance payments $ _ 4. Income of spouse of injured/deceased parent $ _ 5. Student applicant income $ _ 6. Income of other family members residing with applicant: $ _ $ _ $ _ 7. Financial assistance from any state/federal agency (welfare, etc.) $ _ 8. Child support for any child residing with applicant $ _ 9. Other income-litigation, settlement, lottery $ _ Family Assets: Total Value 1. Cash including saving and checking accounts $ _ 2. Stocks, bonds, notes $ _ 3. Real Estate (include home, land, other property) $ _ 4. Automobiles $ _ 5. Other Personal Property $ _ 6. Other Assets $ _ Expected Family Contribution (EFC) from the Student Aid Report (SAR) provided to you after filing out the FAFSA. $ Family Liabilities Total Owed 1. Mortgage $ _ 2. Automobile Loans $ _ 3. Credit Union $ _ 4. Second or third mortgages $ _ 5. Other notes or loans $ _ 6. Other bills not noted above $ _
Family Living Expenses: Monthly Average 1. Rent/house payment $ _ 2. Car payments $ _ 3. Home/Car Insurance payments $ _ 4. Medical/dental bills not covered by work comp $ _ 5. Health Insurance costs $ _ 6. Property taxes $ _ 7. Utilities water, electric, gas $ _ 8. Phone home and mobile $ _ 9. Food $ _ 10. Clothing $ _ 11. Gas/car maintenance $ _ 12. Recreation $ _ 13. Incidentals $ _ 14. Child support payments(to child not residing with applicant) $ _ 15. Other bill payments $ _ I certify that the above information is true and correct to the best of my knowledge and belief. Signature of applicant (and parent if under the age of 18) _ Date Statement of Intent and Authorization for Release of Information: I hereby apply for a scholarship from Kids Chance, Inc. of Tennessee. I hereby consent to the verification of the contents of this application by Kids Chance, Inc. of Tennessee. I hereby consent for Kids Chance, Inc. of Tennessee, its agents, employees or designees to contact and verify any information contained in this application by contact with any individual, government, educational institution, or other entity. I agree to allow the school I attend to send a copy of each quarter s (or semester s) grades to Kids Chance, Inc. of Tennessee. It is fully understood that compliance in this matter is necessary for scholarship awards to be paid on a regular basis. The applicant agrees that should he/she receive additional scholarship funds not set forth in the application above at any time prior to or during attendance of school, the applicant will immediately notify Kids Chance, Inc. of Tennessee to update his/her financial need information. Kids Chance does not sell or share medical, financial, or contact information to outside organizations or agencies. However, if I am awarded scholarship funds, I agree to allow Kids Chance, Inc. of Tennessee to use my name and likeness to advance the charity s purposes and reporting requirements. I agree to provide a photo and testimonial for use on the website and in publications, to attend special events when feasible, and send updates on my academic and extracurricular progress in accomplishing my educational goals at the end of each school year. Signature of applicant (and parent if under the age of 18) Date
Checklist of Required Documents to Complete the Application Process: Completed and signed application. High School Transcript or Technical /College transcript from prior semester. (must include GPA) Copy of Financial Aid Report from the college or technical school you will be attending. Copy of Student Aid Report (SAR) showing the Expected Family Contribution (EFC) from the FAFSA. First Report of injury of parent and a current medical/rehabilitation report. Death Certificate of deceased parent if applicable. Letter(s) of recommendation (optional).