Request for Financial Assistance

Today's Date

Student's First Name

Student's Last Name

Address - Street, City, State, ZIP

Phone Number - (###)###-####

Is Student Employed?
YesNo
 
If Yes - Employer Name

Parent/Guardian Email Address

Is Student related to a FOTHSCI board member?
YesNo
 
Parent/Guardian Name 1

Parent/Guardian Occupation 1

Parent/Guardian Name 2

Parent/Guardian Occupation 2

Amount Requested

Purpose (concert apparel, trip, etc.)

Adjusted Gross Income
—Please choose an option—$25,000 and below$26,000 to $50,000$51,000 to $75,000$76,000 to $99,000$100,000 and above
 
Number of siblings

Age of siblings (separated by commas)

Number of siblings enrolled in college

Please briefly state below the financial circumstances (family or personal) that have led to this application

PARENT SIGNATURE  
Enter your full name as your electronic signature. By providing your name, you acknowledge that the information you have provided on this form is correct and true to the best of your knowledge. You further understand and acknowledge that providing incomplete, incorrect or false information may disqualify the student from receiving financial assistance from the FOTHSCI Board.