Applicant Full Name *

Address

Applicant Address *

City *

State *

Country *

Enter your country

Postal Code *

Applicant Email *

Date of birth *

Phone *

Gender *

Select an option

Parent/Guardian Full Name *

Parent Phone *

Parent/Guardian Email Address *

Parent/Guardian Address *

Applicant’s High School *

High School Address *

Are you age 18 or older? *

Yes

Name and Address of Intended College, University, School or Training Program: *

What type of program are you applying for? *

Summer College

College (Fall & Spring Term)

Trade school

Job training

Continuing education program

Other

If other what is it?

When does this program start? *

What is the length of the program? *

What is the total (one year) tuition of the program? *

If you do not receive a scholarship, will the program be too expensive for you to attend? *

Yes

Are you involved with any programs by CMDSS or at the Buddy Center? *

Yes

If yes, please list CMDSS programs that you have attended in the last 2 years?

If you have not attended any CMDSS programs, is there another personal connection to CMDSS or reason you have not attended programs?

What community, religious, educational, sports, or disability activities or programs are you involved in (other than CMDSS) and how are you involved?

Do you have any previous work or internship experience? *

Yes

If so, please tell us about it

Have you ever attended any other college program or work training program? *

Yes

If so, please tell us about it and when you attended:

What are your future goals and how will attending this program help fulfill them? *

Upload a current picture. *

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PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Upload the acceptance letter to the program you are attending. *

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PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Upload any optional supporting documents.

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PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Applicant must acknowledge the statements below or if the applicant is under legal guardianship or power of attorney, the guardian must acknowledge the statements below:

I acknowledge that all the information submitted is correct and that applicant has not received a previous scholarship from CMDSS.

I acknowledge that if applicant receives a scholarship from CMDSS, the recipient will be available for a presentation photo of the scholarship and that the recipient’s likeness may be used for promotional, marketing or media purposes by CMDSS and/or the program that the recipient will be attending.

Applicant’s Signature *

Clear

Guardian/POA/Parent Signature *

Clear

Relationship to Applicant *