Scholarship Application

First name

Last name

Address

Phone

Contact Preference

Phone

First & Last Name

Enter the names and information of everyone in your household you are requesting receive $100 in scholarship funds.

Birthday

Month

Day

Year

Check if Head of Household

First & Last Name

List everyone in your household you are requesting receive $100 in scholarship funds.

Date of birth

Month

Day

Year

Check if Head of Household

First & Last Name

List everyone in your household you are requesting receive $100 in scholarship funds.

Date of birth

Month

Day

Year

Check if Head of Household

First & Last Name

List everyone in your household you are requesting receive $100 in scholarship funds.

Date of birth

Month

Day

Year

Check if Head of Household

First & Last Name

List everyone in your household you are requesting receive $100 in scholarship funds.

Date of birth

Month

Day

Year

Check if Head of Household

First & Last Name

List everyone in your household you are requesting receive $100 in scholarship funds.

Date of birth

Month

Day

Year

Check if Head of Household

PLEASE ATTACH ONE OF THE FOLLOWING ITEMS TO SHOW THAT YOU QUALIFY FOR THE P&R SCHOLARSHIP PROGRAM. Proof of public assistance such as WIC, Oregon Trail (SNAP or TANF) or Oregon Health Plan. Submit a copy of your benefit letter for Oregon Trail, no cards.