Stanley M Pittman Scholarship Fund
APPLICATION

I understand all of the guidelines on the previous page. I also understand that Sarah Heinz House may share information about the minor child listed on this application with Sarah Heinz House staff and Mr. Pittman for evaluation purposes only. Any information provided beyond staff and Mr. Pittman will be for summary information only and will be kept confidential and will not be associated with any individual member's name. As the applicant, I am also committing that I will keep the information confidential whether or not I received a scholarship and how much I receive.
Child's Name *
E-mail *
Child's primary address *
Child's birthdate *
MM
/
DD
/
YYYY
Phone number *
Parent or Guardian's Name *
Scholarship requested for what SHH program?
Program
After school membership
After school extra programs
Elementary aged day camp
Robotics camp
Resident camp
Preschool day camp
Clear selection
Dollar amount requested? *
Household income (optional)
# in household *
Child or parent's volunteerism & service: *
Why does the child want to participate in the program listed above? *
Parent signature *
Submit
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