Dare to Play Football Scholarship Application

Name of Applicant *

Birth date *

Gender *

Legal Guardian Name *

Phone Number *

Email Address *

Address *

Address

City

State/Province

Zip/Postal

Name of School Applicant Attends (if applicable) *

Current Grade *

Does Applicant receive special services in the school or work *

Please explain *

Total Household Income *

Number of dependents under the age of 21 living in household *

What scholarship option are you requesting? *

Full Scholarship ($25 program fee required)

75% Scholarship ($40)

50% Scholarship ($75)

Please explain any other circumstances that might qualify the applicant for scholarship (e.g., unexpected reduction of income; deployment of parent/guardian; medical expenses, etc.)

I certify that all the information provided on this form is accurate to the best of my knowledge. *

Signature

Date *

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