Stanley M Pittman Scholarship Fund

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APPLICATION

I understand all of the guidelines on the previous page. I also understand that Sarah Heinz House may share information about the minor child listed on this application with Sarah Heinz House staff and Mr. Pittman for evaluation purposes only. Any information provided beyond staff and Mr. Pittman will be for summary information only and will be kept confidential and will not be associated with any individual member's name. As the applicant, I am also committing that I will keep the information confidential whether or not I received a scholarship and how much I receive.

Child's Name *

E-mail *

Child's primary address *

Child's birthdate *

YYYY

Phone number *

Parent or Guardian's Name *

Scholarship requested for what SHH program?

Program

After school membership

After school extra programs

Elementary aged day camp

Robotics camp

Resident camp

Preschool day camp

Clear selection

Dollar amount requested? *

Household income (optional)

# in household *

Child or parent's volunteerism & service: *

Why does the child want to participate in the program listed above? *

Parent signature *

Submit

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