PAGNOZZI CHARITIES YOUTH SPORTS
SCHOLARSHIP PROGRAM
100 E. Poplar, Suite. A
Fayetteville, AR 72703
479-443-2550
fax: 479-587-9142
www.pagnozzicharities.org
kelley@pagnozzicharities.org
Part 1. Applicant Information - REQUIRED
Child's Name: M F   Grade:
Sport Camp 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 and must be submitted, at least, 2 weeks prior to registration deadline to allow time for processing. * Proof of all household income for the previous month or foodstamp verification dated within the last 30 days * Copy of completed sports registration (turn original in as directed on registration form) * League information and contact person (if registration is not available).
Completed Applications can be submitted by mail, email, fax or brought by our office.
Part 3. List ALL Household Members/Income from Last Month- REQUIRED
Receive Food Stamps 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
   Attachment (1MB limit):