Scholarship application — HAIEA - Human-Animal Interaction and Education Advocates

Complete this form for the child you are requesting a scholarship. All information must be complete and accurate.

Email paystubs for the last 4 weeks for all adults contributing to the family income to volunteers@cathyscritters.com.

Child’s Name

First Name

Last Name

Date of Birth

YYYY

Grade entering

Parent/Guardian 1 Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Place of Employment

Employers Address

Employers Phone

Parent/Guardian 2 Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Place of Employment

Employers Address

Employers Phone

Number of people in your household (including adults)

Gross Monthly Family Income

Additional Income (Welfare AFDC, Child Support, Social Security, WIC, CHIP, Medicaid - include dollar amounts)

What week of Critter Camp is preferred?

Briefly explain the reason for your request.

By checking this box, your are verifying that the information provided is true and accurate.

I agree