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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
PLE
A
SE
FILL
OUT
THIS
F
ORM
C
OMPLETE
L
Y
Summer
Camp
Schola
r
ship
Guidelin
e
s:
•
Applica
n
ts
a
r
e
e
v
alu
a
t
ed
without
r
eg
a
r
d
t
o
r
a
c
e
,
r
el
i
gion,
n
a
tu
r
al
or
i
gin,
s
e
x
or
p
hy
sical
abilit
y
.
•
F
undi
n
g
is
limi
t
ed
and schola
r
shi
p
s
a
r
e
n
o
t
gua
r
a
n
t
eed
t
o
all
applica
n
ts.
•
S
t
aff
o
f
Cheza Nami Foundation
,
I
n
c
.
and
their
child
r
en
a
r
e
n
o
t
el
i
gible
f
or schola
r
ship
assi
s
t
an
c
e
.
•
Schola
r
shi
p
s
m
a
y
n
o
t
be
a
w
a
r
ded t
w
o
y
e
a
r
s
in
a
r
o
w
.
•
I
n
c
ompl
e
t
e
applic
a
tions
will
n
o
t
be
r
e
vi
e
w
ed.
•
Schola
r
shi
p
s
will
be
a
w
a
r
ded
based
on
need.
Completion of the form below does not guarantee Scholarship Award. Please submit one application per child.
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
*
6th grade
7th Grade
8th Grade
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
IN
F
ORM
A
TION
E
l
i
gibility
f
or
need-based
schola
r
shi
p
s
is
based
on
the
f
oll
o
wi
n
g cri
t
eria
and
c
onditions,
includi
n
g
household
si
z
e
*
and
in
c
ome
s
t
anda
r
ds.
I
f
an
applica
n
t
does
n
o
t
f
all
within
these
cri
t
eria
but
can p
r
ov
e
o
ther
special
ci
r
cum
s
t
an
c
es,
the
schola
r
ship
c
ommit
t
ee
will
r
e
vi
e
w
and
m
a
y
g
r
a
n
t
a
schola
r
shi
p
.
*
H
o
u
s
e
h
o
l
d
in
c
l
ud
e
s
all
p
e
o
p
l
e
(
a
du
l
t
s
and
c
hi
l
dren)
living
in
the ho
u
s
e
h
o
l
d
,
r
e
l
a
te
d
or
n
o
t
(
grandparen
t
s
,
o
ther
r
e
l
a
tiv
e
s
,
fr
i
en
d
s
,
e
t
c
.).
P
l
e
ase
indic
a
t
e
y
our
to
t
al
an
n
ual
household
in
c
ome
f
r
om
all
sou
r
c
es
(includi
n
g
w
a
g
es,
i
nt
e
r
e
s
t
in
c
om
e
,
i
n
v
e
s
tme
n
ts,
alimo
n
y
,
child
s
uppo
r
t
,
social securit
y
,
public
assi
s
t
an
c
e
):
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
✕
