PAGNOZZI CHARITITES YOUTH SPORTS
SCHOLARSHIP PROGRAM
26 W Center St Suite 204
Fayetteville, AR 72701
479.443.2550
fax: 479.587.9142
michelle@pagnozzicharities.org
Part 1. Applicant Information - REQUIRED
Child's Name: Male Female   Grade:
Sport Camp Instructional Equipment Other
Program name and/or specific equipment scholarship is for:
Part 2. Additional Information - REQUIRED
The following information is REQUIRED to complete the application for processing. Completed Application must be submitted, at least, 2 weeks prior to event/start date to allow time for processing. * Proof of all household income for the previous month. * Copy of completed registration (turn original in as directed on registration form). * Facility/class information and contact person (if registration is not available).
Part 3. List ALL Household Members/Income from Last Month- REQUIRED
Receive Food Stamps Yes No Free Lunch Program Yes No
(List EVERYONE in household)
First  Last    Age
Gross Income /
How often received		 Welfare, child support,
alimony		 Pensions, retirement,
Social Security		 Other Check if
no income
Jane Doe (Example)  30
$300/ bi-monthly (Ex) $150/weekly (Ex) $600/monthly (Ex)    
$ $ $ $
$ $ $ $
$ $ $ $
$ $ $ $
$ $ $ $
$ $ $ $
$ $ $ $
$ $ $ $
Part 4. Signature and Personal Information (Adult must Sign)
I certify (promise) that all information on this application is true and that all income is reported. I understand that Pagnozzi Charities officials reserve the right to request more information and verify (check) the information. I, also, understand that Pagnozzi Charities is not responsible for injury or loss of property while participating in above scholarship activity. I do, hereby, release Pagnozzi Charities, it's employees, sponsors & Board of Directors from any liability for any accident or injury.
Signature:      Today's Date:
Home Phone # Work Phone # Message Phone #
Street or Rural Address : City:
State: Zip:       Email Address:
Part 5. Demographic Information
Name of School County of Residence
Part 6. Child's racial and ethnic identities (optional)
Caucasian African-American Native American Native Hawaiian
Hispanic or Latino Asian Multi-Racial Other Pacific Islander