Name:_____________________ Address:________________________ Phone:___________

List all household members: Relationship

1.______________________________________

2.______________________________________

3.______________________________________

4.______________________________________

5.______________________________________

6.______________________________________

7.______________________________________

8.______________________________________

Brief statement of circumstances that the Committee should consider: (Back of Form)

Signature of Applicant(s)__________________________________________ Date_________

Fulfilling all Parent Involvement Hours and participation in the Certificate Program ($4,000 minimum purchase) and Tuition Raffle (must purchase 3 tickets per student) are required to be considered for Adopt A Student Aid. Application will be rejected if the criteria are not met.