Scholarship Application For

__________________________________

Student Name______________________________________________________

Parent Name _______________________________________________________

Home Phone_______________________Parent’s cell ______________________

Email:_____________________________________________________________

School Attending___________________________ Grade_______ Age_________

Does student receive school lunch assistance this year? ____Yes ____N

Has student received TPI scholarships before? ____Yes ____No

If yes, when & in what amount?________________________________________

What is your current approximate annual household income? (please circle one)

$20,000 or less $36,000- $40,000 $50,000- $60,000

$25,000- $29,999 $41,000- $45,000 $60,000- $70,000

$30,000- $35,000 $46,000- $50,000 Above $70,000

How many family members are in your household? _________________________________

Indicate the level of help your family needs: _____25% _____50% _____100 %

Scholarships are awarded with the following understanding:

1. Student will attend class regularly with little or no absences.

2. Behavior will be respectful of peers, instructors & building.

3. Student has reliable transportation to & from workshop.

4. Partial scholarship recipients will pay remainder due to TPI with-in 2 weeks of scholarship notification. Late
payments will be subject to $10/week late fee.

5. This form must be completed in full for scholarship eligibility.

I understand & agree to the above requirements.

PARENT/GUARDIAN SIGNATURE:_____________________________ DATE_____________

Titusville Playhouse, Inc. 301 Julia St. Titusville, FL 32796

(321)268-1125 Fax:(321)264-2976
www.titusvilleplayhouse.com