PARENT EDUCATION PROGRAM/PARENT ADVISORY COUNCIL

SCHOLARSHIP APPLICATION FORM

Scholarships are awarded on the basis of financial need to those families who could not otherwise afford to participate in a Parent Cooperative experience or to those experiencing a temporary financial emergency.

Date _______________________ Quarter applied for ______________________________

AM

Co-op name __________________________________ PM Age group ____________

N.S.C.C. Parent Education Instructor’s Name _____________________________________

Child’s Name _______________________________________ Age ______________

Address _________________________________________ Telephone _____________

(area code)

Parent’s Name _______________________________ Occupation __________________

Currently Employed ____________________ Full-time __________ Part-time _________

hrs/wk

Parent’s Name _______________________________ Occupation __________________

Currently Employed ____________________ Full-time __________ Part-time _________

hrs/wk

Parent’s address if different from child’s _________________________________________

Number of children in family _________ Ages __________ School Placement __________

Public _____ Private _____

Treasurer: Please complete this portion prior to applicant filling out this form.

_______________________ ____________________ ‘s monthly tuition is ____________

Co-op name Age group

Please exclude extended days, pro-rated May/June, registration fees, etc. and sign below to verify tuition and enrollment of applicant in the co-op program. Awards will be sent directly to the treasurer, so please print your address and phone number.

________________________________________________ ___________________

Treasurer’s signature Telephone

_________________________________ _________________ _______________

Address City Zip

Scholarships are limited to 50% of monthly tuition, with above noted exclusions.

½ month tuition $ ______________________ X 3 = ______________________

Total quarter request

(Some families qualify for 75% of tuition, based on NSCC income guidelines. The Parent Educator notifies the scholarship committee, treasurer and student if the student's income qualifies the family for NSCC quarterly tuition waiver eligibility / 75% scholarship.)

PLEASE USE SEPARATE FORM FOR EACH CHILD

The following information is necessary to determine need and will be held in the strictest of confidence.

NET INCOME FIXED MONTHLY EXPENSES

(monthly take-home pay)

Salary ____________ Rent/Mortgage ________________

Rents rec’d ____________ Utilities ________________

Alimony ____________ Food (Avg. Amt.) ________________

Child Support ____________ Insurance (car, health, life) ________________

Interest/ Vehicle, gas, bus ________________

Dividends ____________ Credit Cards ________________

Other ____________ Loans ________________

Medical, Dental ________________

Other/please list (diapers

clothing, toiletries) ________________

Preschool tuition ________________

TOTAL MONTHLY INCOME $_______________ TOTAL MONTHLY EXPENSES __________

Total number of family members living in home __________

Please describe the circumstances which make tuition assistance necessary. If additional space is needed, please use another page.

Total quarter request ____________________ ____________________________

(not to exceed amount Signature of enrolled parent

in treasurer’s section)

Applications are due AT NSCC by*: Mail to: Scholarship Committee

3^rd Friday of Sept. for Fall Qtr. Parent Education program

1^st Friday of Dec. for Wtr. Qtr. NSCC

1^st Friday of Mar. for Spr. Qtr. 9600 College Way N.

Seattle, WA 98103

* Timely Applications will be considered for available funds. Late applications may be considered if additional funds are available.

Parent Education Instructor: Please comment on applicant’s involvement in the co-op and/or expand on the family situation to support the need for scholarship assistance.

____________________________

Instructor’s Signature

This family qualifies for tuition waiver:	_________
	(yes or no)

Revised 5/07