IF Scholarships

APPLICATION FOR SCHOLARSHIP BASED ON FINANCIAL NEED

THE IRMA FREEMAN CENTER FOR IMAGINATION

5006 Penn Avenue, Pittsburgh, PA 15224

412 - 924 - 0634

IRMA FREEMAN SCHOLARSHIP FUND PROGRAM

2009 CAMP, CLASSES and WORKSHOPS

PLEASE READ THE ENTIRE APPLICATION THOROUGHLY & COMPLETE THE CHECK LIST BEFORE TURNING IN THE APPLICATION!

APPLICATIONS WILL ONLY BE PROCESSED ONCE ALL DOCUMENTS ARE SUBMITTED AND THE APPLICATION FILLED OUT COMPLETELY. IF AN APPLICATION IS SUBMITTED WITHOUT THE PROPER DOCUMENTATION, THE APPLICATION WILL BE RETURNED WITH A LETTER STATING WHAT ADDITIONAL INFORMATION IS REQUIRED.

One of the following documents are required for the processing of a scholarship:

• Explanation of why you are in need of financial assistance (complete “Your Story”)

• Copy of 2008 tax return (form 1040 and all W-2’s)*

• Copy of last two (2) paycheck stubs and/or a letter from your employer verifying your current salary.

• Copy of Unemployment Income Verification letter

• (Copy of Social Security or Disability award letter

• If receiving food stamps or TANF, a copy of food stamps or TANF award letter

• If you are a full time student, provide documentation confirming your full-time enrollment status

*If you have any questions or need any additional information, please contact Sheila Ali at the Irma Freeman Center for Imagination at 412-924-0634 or email Sheila Ali at sheiladali@irmafreeman.com

**Note: If you do not have a copy of your tax return, you may obtain a copy by contacting the Internal Revenue Service (1-800-829-1040).

***Additional documents may be requested.

****Membership scholarships must be claimed within 10 days of approval. If scholarships are not claimed within the time allowed, you will may lose your scholarship or need to reapply.

*****All applications are based on household information.

The Irma Freeman Center for Imagination (the IF Center) will assess scholarships throughout the summer; however scholarships are given on a first come first serve basis and may be limited to one per session. during the month of March. You may contact the If Center after June 13th to check the status of your application.

PLEASE INDICATE YOUR NEED BY CHECKING THE APPROPRIATE REQUEST:

Is this for Class? Yes____ No____

If yes, which Class? ____________________________________________

Is this for Workshop? Yes____ No____

If yes, which Workshop? ___________________________________________

PERSONAL INFORMATION:

Name_________________________________ Date of Birth______________ Age____

Address_________________________________________________________________

City__________________ State_______ Zip_______ Phone#_____________________

E-Mail Address___________________________________________________________

Are you a full time student? ____If yes, where? ____________

Are you married? ________ Spouse’s name_______________

Date of Birth__________

Is spouse a full-time student? ______ If yes, where? ______________

List names (including YOURSELF and last names if different from the applicant) and ages of all dependents (those you claim on your Federal Tax’s):

1. __________________________ Age ________ DOB _________ M / F

2. __________________________ Age ________ DOB__________ M / F

3. __________________________ Age ________ DOB ___ ______ M / F

4. __________________________ Age ________ DOB _ ________ M / F

5. __________________________ Age ________ DOB__________ M / F

6. __________________________ Age ________ DOB__________ M / F

Employment Information

Employer______________________________ Position__________________________

Employer Address________________________________________________

City_________________ State________ Zip ______ Phone# ______________________

Supervisor’s Name__________________________ Phone#________________________

Gross Monthly Income $____________________ How long at this current job?

________

Spouse or Second Adult’s Employment Information

Employer______________________________ Position__________________________

Employer Address____________________________________________________

City_________________ State________ Zip ______ Phone# ______________________

Supervisor’s Name__________________________ Phone#________________________

Gross Monthly Income $__________ How long at this current job? ______

How many adults are in your household? _____ How many children? ____

Does any member of your household receive any of the following? Check those that apply. Please provide documentation to support your choices.

YES NO MONTHLY INCOME

TANF _____ ______ _____________________________

Food Stamps _____ ______ _______________________

Social Security _____ ______ ______________________

Disability _____ ______ ___________________________

Child Support _____ ______ _______________________

Alimony _____ ______ ____________________________

Unemployment _____ ______ ______________________

Pension/Retirement _____ ______ __________________

Do you share expenses with anyone else in your household? Yes____ No____

FOR STAFF USE ONLY:

DATE RECEIVED:

_________________________

YOUR STORY

Your story will allow us to tell donors how their money is being used to make a difference in our community. The story may be used in publication or other public material to illustrate how Partner With Youth donations are impacting the lives of children, adults, and families. Name and personal information, such as salary, will always remain confidential. Attach additional pages if necessary.

_____________________________________________________________________________

Please confirm that you have included all of the necessary documentation by completing the following checklist:

_________ Complete application.

One of the following:

_________ Explanation of why you are in need of financial assistance (complete “Your Story”)

_________ Copy of 2008 tax return (form 1040 and all W-2’s)*

_________ Copy of last paycheck stub and/or a letter from your employer verifying current salary.

_________ Copy of Unemployment Income Verification letter

_________ Copy of Social Security or Disability award letter

_________ If receiving food stamps or TANF, a copy of food stamps or TANF award letter

_________ If a full time student, provide documentation confirming full-time enrollment status

I verify that all of the information and documentation is true, complete, and accurate. If my situation changes, I agree to notify the Irma Freeman Center for Imagination within 30 days. If I submit incorrect information or do not notify the Irma Freeman Center for Imagination within 30 days, I acknowledge that I will be terminated from this financial assistance program.

Signature __________________________________________________________________ Date______________________________

Signature of Executive Director ____________________________________________________

Date ________________________________