Summer Camp 2016 - Scholarship application

2016 DIVERSTIY CAMP SCHOLARSHIP APPLICATION - For Tri-Valley Students only

Middle school students interested in the Cheza Nami summer Camp-2015 and needing financial assistance are invited to complete the scholarship application form below. Selected students will be invited to register for the camp on June 10th. Scholarships are limited. Application deadline: June 17th

For Questions, email scholarships@chezanami.org or call 925-398-3827

PLEASE FILL OUT THIS FORM COMPLETELY

Summer Camp Scholarship Guidelines:

•     Applicants are evaluated without regard to race, religion, natural origin, sex or physical ability.
•     Funding is limited and scholarships are not guaranteed to all applicants.
•     Staff of Cheza Nami Foundation, Inc. and their children are not eligible for scholarship assistance.
•     Scholarships may not be awarded two years in a row.
•     Incomplete applications will not be reviewed.
•     Scholarships will be awarded based on need.

Completion of the form below does not guarantee Scholarship Award. Please submit one application per child.

* Indicates required field

Name of Child *

First

Last

Birth Date *

Please provide the applicant's date of birth.

Phone Number *

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Incoming Grade? Select One *

School *

What do you hope your child will gain from this experience? *

Has your child participated in any of Cheza Nami's programs in the past? *

Yes No

If Yes, please list *

REQUIRED FAMILY INFORMATION

Father's Information

Father's Name *

First

Last

Mother's Name *

First

Last

Address (if different) *

Line 1

Line 2

City

State

Zip Code

Country

Place of Employment *

Address (if different) *

Line 1

Line 2

City

State

Zip Code

Country

Place of Employment *

Name of Legal Guardian (if not living with mother/father) *

REQUIRED FINANCIAL INFORMATION

Eligibility for need-based scholarships is based on the following criteria and conditions, including household size* and income standards. If an applicant does not fall within these criteria but can prove other special circumstances, the scholarship committee will review and may grant a scholarship.

*Household includes all people (adults and children) living in the household, related or not (grandparents, other relatives, friends, etc.).

Please indicate your total annual household income from all sources (including wages, interest income, investments, alimony, child support, social security, public assistance):

Choose One *

Below $10,000 $10,001-$15,000 $15,001- $20,000 $20,001-$25,000 $25,001-$30,000 $30,001-$35,000 $35,001-$40,000 $40,001-$45,000 $45,001-$50,000 $50,001 - $55,000 $55,001-$60,000 $65,001-$70,000 Over $70,000

Are there any extenuating circumstances, permanent or temporary, that make financial assistance necessary at this time? *

Are other family members currently applying for assistance? *

Yes No

Has anyone in your family previously received a scholarship to attend a Cheza Nami Diversity Camp? *

Yes No

If yes, when? *

Submit Scholarship Application Form

P: 925 398 3827
E: info@chezanami.org
Mailing Address
5424 Sunol Blvd., Ste. 10-153,
Pleasanton, California 94566
Tax ID# 27-4568585

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