Date of Application

Beginning Date of Student’s 2008/09 School Year

Student’s Full Legal Name – Last, First, Middle

Grade Placement for 2008/09 School Year (Ex. 5^th Gr.)

Student’s Physical Address

Student’s Mailing Address – If different

Student’s Date of Birth

Student’s Place of Birth – City/State/Country

Student’s Social Security # if US Resident ** REQUIRED**

Student’s Sex

Student’s Race

Student’s Telephone Number

Student’s or Family’s Email Address

Father’s Full Name

Father’s Driver’s License Number (Security Reasons)

Father’s Place of Employment

Father’s Title/Rank/Occupation

Father’s Work Phone Number

Circle one:  Type of  Employment

             Full  Time                 Part Time

Mother’s Full Name

Mother’s Driver’s License Number (Security Reasons)

Mother’s Place of Employment

Mother’s Title/Rank/Occupation

Mother’s Work Phone Number

Circle one:  Type of  Employment

                Full  Time                 Part Time               

Church Name and Number – If Applicable

Pastor’s Name and Number

Circle one reporting frequency:               YEARLY                 SEMESTER

Amount:  $______________________