Impact Bay Area - Scholarship Application
Please FULLY COMPLETE this application. All information will be kept confidential. For help, please contact: info@impactbayarea.org
First Name *
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Last Name *
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Street Address *
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City *
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State *
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Zip Code *
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Cell Phone with Area Code *
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Alternative Phone Number with Area Code
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Email *
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What's the best way to contact you?
Demographic Information
All demographic information increases Impact Bay Area’s understanding of the populations we serve, and answers will not influence award decisions.
Date of Birth
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DD
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YYYY
Age
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Gender
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Orientation
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Race/Ethnicity
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Number of Members in Your Household
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Monthly Gross Income *
Gross income is the income before taxes are deducted.
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Current Source of Income (if any)
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We use the following income guidelines to give individuals preference for scholarship funds
Family Size Family Income (gross monthly)
1 $1,164
2 $1,576
3 $1,989
4 $2,401
5 $2,814
6 $3,226
6+ (add $413 per each add’l person)
We recognize that an applicant whose income exceeds the above levels may be in a situation which makes it extremely difficult for him/her to afford an Impact class without scholarship assistance. If this describes you, please explain (in the space below) why you need a scholarship.
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We also invite you to share with us any additional information about why you want to take an Impact class (include any information you feel is important such as life situation, history of assault or abuse, current dangers/fears, referral by therapist or victim advocate, etc.).
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We require all scholarship recipients to make a co-pay to reserve their space in a class. There are a limited number of scholarship spots in each class and your co-pay shows your commitment to the course. If selected for scholarship assistance, we ask that you pay at least the minimum co-pay, but we encourage you to pay what you can afford, as follows:
Women’s Basics (reg. $595) Scholarship Sliding Co-Pay Range: $50-$500
Teen Course (reg. $275) Scholarship Sliding Co-Pay Range: $50-$200
Intro Class (reg. $75) Scholarship Sliding Co-Pay Range: $25-$50
Please list the NAME and DATE of the course you want to take, as well as the amount of co-pay you are able to contribute: *
Example: Women’s Basics, April 2014, $200 co-pay
Your answer
Backup Choice: Please list the NAME and DATE of your 2nd choice for a class, as well as the amount of co-pay you are able to contribute. *
Example: Women’s Basics, May 2014, $200 co-pay
Your answer
Testimonials from our scholarship recipients is an important part of our ability to raise money to provide scholarships for others. If awarded a scholarship, you agree that after you take the class you will provide Impact Bay Area with a short statement of your experience and why receiving financial assistance was important to you. This statement may be in used online and print media for promotional and fundraising purposes.
Please type your full name below as an electronic signature that confirms that the information you have provided in this application is true and correct. *
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