emPOWER kids Scholarship Application

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You may fill out this form for your own child/family or on behalf of another family.

Applicants who receive financial assistance may be offered a recurring monthly Scholarship Membership with documentation from aid sponsor (TANF, SNAP, Free/Reduced Lunch, school statement, etc.)

Email *

Application for: *

your family/child

on behalf of someone else

Other:

Caregiver's Email Address *

Caregiver Last Name *

Caregiver First Name *

Caregiver Phone Number *

Child First and Last Name *

Child’s Birthday *

YYYY

Child's Gender Pronouns *

Please briefly describe why this child should receive an emPOWER kids Scholarship. *

Will the child require any modifications or accommodations to have a successful class experience? If yes, please describe. *

Optional: Does applicant receive financial assistance? Applicants who receive ongoing financial assistance may be offered a recurring monthly Scholarship Membership with documentation from aid sponsor (TANF, SNAP, Free/Reduced Lunch, school statement, etc.)

Yes

Unsure

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A copy of your responses will be emailed to the address you provided.

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