Consent Form for Empower Her's Christina's Heart Scholarship
Christina's Heart Scholarship:
Christina's Heart Scholarship is in memory of Christina Logue, a loving and giving community member, wife, mom and friend. Two scholarships per year will be given to contribute to covering ​the expenses of an extracurricular activity for a child in need. The Scholarship Award Amount for 2019 is (up to) $250.

The Criteria for Christina's Heart Scholarship:
-Grades K-12
-Loss of Parent/Severely Ill
-Lives in Orange, Woodbridge or Bethany
-In need of money to take a lesson or participate in sports/scouts/etc.
-Application must be filled out by a School Counselor, School Social Worker, School Psychologist or School Administrator
-Child should be an upstanding student and school citizen
-Parent/Guardian consent must be given to school employee to submit application.

This form provides consent of Parent/Guardian of the nominated child for Empower Her's Christina's Heart Scholarship. Your child is being nominated by a Social Worker, Psychologist or Administrator from your child's school.
Parent/Guardian Full Name *
Your answer
Child's Full Name *
Your answer
Child's School *
Your answer
I give my child's school permission to nominate my child for Christina's Heart Scholarship. *
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