Temple Israel Program Scholarship Request Form

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The Temple Israel Scholarship Committee meets in February, May, August, and November of each year. Please fill out the information below to apply for a scholarship. Please note that for Temple Israel programs, a completed program registration is required before you can submit a scholarship application.

Learner Information

Learner's age is:

Learner first name:

Learner last name:

Learner email:

Learner phone:

Learner is financially dependent on parent(s)/guardian(s).

Learner has:

What is your relationship to the learner?

What is your name (first and last)?

Please specify your relationship to the learner:

Is this learner involved in any other programs at Temple?

Please list:

Since funds are limited and scholarships are awarded based on financial need, please use the space provided below, to explain your family’s current financial situation or any special circumstances which would pertain to this request for assistance.

Due to the limited nature of scholarship funds and the increased demand for these funds, we ask that you inform the Scholarship Committee if your circumstances change.

Program Information

For which program area are you seeking a scholarship?

What is the name of the program?

How long is the program?

Please briefly describe the program and its purpose:

For which specific program are you seeking a scholarship?

Total cost of program:

Learner/family contribution:

Amount requested from Temple Israel:

Have you applied for or received a scholarship for this program from any other source?

Please list the source(s) of the scholarship(s) to which you have applied and the amount for which you have applied:

Learner Income Information

Employer:

Occupation:

Gross annual income:

Marital status:

Check if you receive:

AlimonyChild supportOther income

Annual alimony amount:

Annual child support amount:

Annual income from other sources:

Number of people in your household:

Parent/Guardian 1 Information

P/G 1 first name:

P/G 1 last name:

P/G 1 email:

P/G 1 primary phone:

P/G 1 employer:

P/G 1 occupation:

P/G 1 gross annual income:

P/G 1 marital status:

Check if you receive:

AlimonyChild supportOther income

Annual alimony amount:

Annual child support amount:

Annual income from other sources:

Number of people in your household:

Parent/Guardian 2 Information

P/G 2 first name:

P/G 2 last name:

P/G 2 email:

P/G 2 primary phone:

P/G 2 employer:

P/G 2 occupation:

P/G 2 gross annual income:

P/G 2 marital status:

Check if you receive:

AlimonyChild supportOther income

Annual alimony amount:

Annual child support amount:

Annual income from other sources:

Applicant signature (type full name):

Application date:

Email for confirmation:

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