Boys & Girls Club of Hood County

Scholarship Application

Dependent’s Full Name                                                                                                      

Address                                                                       City                                                 

State                           Zip                                          Phone                                               

Social Security Number                                                         Date of Birth                      

School                                                             Grade                                                          

Sex        Male           Female

Race/Ethnic group:        African American        Native American        Hispanic/Latino     

Caucasian        Other

Parent Information

Name                                                                          Date of Birth                                  

Address (if different than child)                                                                                         

Phone Number                                                           Cell Phone                                       

Marital Status:    Married      Separated      Divorced      Widowed      Single

Education:   (What is the highest level of education you have attained)

            Elementary

Junior High (6-8 yrs)

                High School

                4-year College (14-15 yrs)

Sex:      Male        Female

Relation to Child:   Mother      Father      Stepmother      Stepfather      Grandparent      Legal Guardian

Are you or any member of your household disabled/handicapped?                                 

Does your child/children receive free/reduced lunch?  If yes, which one              

WORK

Place of Employment                                                                                                

Position Title                                                                                                                       

Full Time                    Part-Time                  How many hours a week                              

SPOUSE/PARTNER INFORMATION

Name                                                                          Date of Birth                                  

Address                                                                                  City                                     

State                           Zip                              Phone                                                          

Is spouse living in household with child?  If NO does spouse contribute in child

support for the child above, how much?                                                       

SPOUSE WORK INFORMATION

Employer                                                                                                                             

Address                                                                                  City                                     

State                           Zip                              Work Phone                                               

Total Monthly Household Income (NET)                                                                            

 My child has had the following involvement with the Boys & Girls Club of Hood County (leagues, programs, camps)

Please List All Members of Household

Name                                                  Age                             Grade/School (if applicable)

By signing this form, I agree to the following:

1. I understand that I much attach a copy of the most recent income tax form, paycheck stub, and a copy of any state assistance in which I receive including TANF, Lone Star, Medicaid, Medicare, Free/Reduced Lunch, etc.

2. I give Boys & Girls Club of Hood County permission to verify my employment, my salary, my family income, and information reported on my enclosed tax return.

3. I understand that it is my responsibility to report any change in my employment status, any change of address, any change of dependent care, and any change in family income; I understand that providing inaccurate information may result in disqualification form this program.

4. I understand that by filling this out does not secure my child a scholarship, but places him/her in the next step of the scholarship selection committee process.

Signature                                                                                Date