Date of Application

Student Name

Date of Birth

Current School Grade

School

Do you have additional students applying for a scholarship

2nd Student Name

2nd Student Date of Birth

2nd Students Current School Grade

2nd Student School

Do you have additional students applying for a scholarship

3rd Student Name

3rd Student Date of Birth

3rd Student Current School Grade

3rd Student School

Parent/Guardian Name

Contact Phone Number

Alternate Phone Number

Email address

Mailing Address

City, State and ZIP Code

General Guidelines

Please read and type name below indicating that you understand and agree to comply with General Guidelines

Scholarship money is available for students that demonstrate a financial need. Scholarships will be provided based on family need demonstrated through both household size and income and in some cases by school principal and/or counselor recommendations.
Only ONE scholarship form is required per household.
Scholarships are awarded on a first come, first served basis.
The Ernest L. McKinney Scholarship has three semesters: Fall, Spring, and Summer.
Each child that is awarded a scholarship will have access to one course/workshop per semester.
Returning scholarship applicants must fill out new forms before each Fall semester.
Applicants should submit a completed application along with the required documentation on or before the registration deadline.
Only completed applications submitted before the stated deadline will be considered. Incomplete applications will not be eligible for consideration.
Once a decision has been made, the applicant will receive written notice as to whether or not scholarship money is available.
Scholarships will not be retroactive.
Partial scholarships may be awarded. If the student is awarded a partial scholarship, you will be asked to submit payment of the remaining balance by the last day of registration.
There are no refunds after the last day of registration.

Guardian to type name here to agree with General Guidelines

Documentation Requirements

Proof of income includes a copy of current pay stub for all members of your household who get paid for working. Additional proof of income include: IRS 1099 Form, W-2 Form, letter from employer, Social Security statement, bank statement, court ordered awards letter, free/reduced school breakfast and food approval letter or letter from DSC or other foster care organization.

Upload your proof of free/reduced breakfast and lunch program

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Upload 2nd proof of income, if needed

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Upload 3rd proof of income, if needed

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If you are unemployed please check here

Name of Employer

Employer Address

Employer Phone Number

Rate of pay and how often

Include a brief statement containing your work hours

How many children live in your home? List all children and ages who live in the household

List all other adults living in your household (not including yourself). Write NA for adults not employed. If employeed, list their employer and pay rate.

#1 Name living in household

#1 Employed with

#1 Rate of pay & How often

#2 Name living in household

#2 Employed with

#2 Rate of pay & How often

#3 Name living in household

#3 Employed with

#3 Rate of pay & How often

Do you need additional space to list people living in household?

Names of additional persons living in my household

List any additional income sources for yourself or any other adult in your household such as Alimony, Social Security Benefits, Food Stamps, SSI etc. Write NA if there are no additional income sources.

#1 Name of person with additional income

#1 Type of funding received

#1 Amount of additional income

Are there any more people in household that receive additional income

#2 Name of person receiving additional income

#2 Type of funding received

#2 Amount of additional income

Are there any more people in household that receive additional income

Do you need additional space?

Additional information

List any additional financial assistance for yourself or anyone else in your household, such as housing assistance (HUD) or utility/energy assistance. (Write NA if none)

#1 Name of person receiving assistance

#1 Type of funding received

#1 Amount received

#2 Name of person receiving assistance

#2 Type of funding received

#2 Amount

I understand that my employers may be called to verify monthly income. I understand if I have made any misrepresentation on this application I will be asked to return any scholarship money received. Scholarship applications are reviewed on a semester basis, and ARE NOT retroactive. I verify that all information on this form is an accurate representation of my family's annual income.

Checkbox*

Student Preferences & Additional Conditions

1st Child's Name

1st Child's First Choice Class

1st Child's Second Choice Class

1st Child's Third Choice Class

2nd Child's Name

2nd Child's First Choice Class

2nd Child's Second Choice Class

2nd Child's Third Choice

Please list any other children and their class preferences

By providing names here you agree to complete 10 hours of volunteer work during the scholarship semester.

Parent/Guardian signature

Student Signature

Date

By typing name you agree to ensure that the student will be at every class meeting and understand that missing class may result in loosing future scholarship opportunities.

Parent/Guardian Name

By typing name you (the student) agrees to be at every class meeting and understand that missing class may result in loosing future scholarship opportunities.

Student Name

Date

Check Here if you need to communicate with staff regarding any extenuating circumstances of financial strain that should be considered as part of this application, i.e. medical bills

By typing name below and submitting the application electronically, I certify that to the best of my knowledge and belief that all of the information contained is correct and complete. I understand if I have made any misrepresentation on this application I will be asked to return any scholarship money received.

Parent/Guardian Signature electronic

Date Field

If you have any questions you may email the Director at theresah@jonesboroughtn.org

The McKinney Center is located at 103 Franklin Avenue, Jonesborough, Tennessee 37659

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