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Part 1. Applicant Information - REQUIRED |
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Part 2. Additional Information - REQUIRED |
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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.
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Part 3. List ALL Household Members/Income from Last Month- REQUIRED |
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Part 4. Signature and Personal Information (Adult must Sign) |
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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:
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Part 5. Demographic Information |
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Part 6. Child's racial and ethnic identities (optional) |
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