Scholarship Application

Please be sure to complete all requested information and sign on the bottom of the form.

Parent First Name *

Parent Last Name *

Email Address *

Phone *

Street Address *

City *

State *

Postal Code *

Leave a Message

Marital Status (Head of Family) *

Mother's Yearly Income *

Mother's SSN *

Mother's Occupation *

Father's SSN *

Father's Yearly Income *

Father's Occupation *

What is your family total income before deductions? *

What is your total Salary *

Salary Period *

Monthly

Yearly

Monthly Rent/Mortgage *

Do you own your home? *

Yes

No

How many cars do you have? *

Total amount of Car Payments *

How many children are in your family? *

When was your last family vacation? *

How much did the vacation cost in total? *

School(s) my child(ren) attend *

List annual tuition cost for each child *

Does your family receive Medicaid? *

Yes

No

Medicaid #

Welfare Assistance or Food Stamps? *

Yes

No

I am requesting this scholarship for *

Hebrew School

Bat Mitzvah Club

'The Tribe'

How much do you feel you can afford to pay? *

What are your reasons for requesting this scholarship? *

Signature of Parent *

The information you provide will NOT be shared with any third party organisations.

Chabad of Winter Garden