Required Promise Scholarship Information
Parent #1
Last Name
Your answer
First Name
Your answer
Street Address
Your answer
City, State, Zip
Your answer
Home Phone
Your answer
Cell Phone
Your answer
Email
Your answer
Parent #2
Last Name
Your answer
First Name
Your answer
Street Address
Your answer
City, State, Zip
Your answer
Home Phone
Your answer
Cell Phone
Your answer
Email
Your answer
Student Information
Last Name
Your answer
First Name
Your answer
Street Address
Your answer
City, State, Zip
Your answer
Home Phone
Your answer
Cell Phone
Your answer
Email
Your answer
Date of Birth
MM
/
DD
/
YYYY
School Name
Your answer
Grade Enrolled in Fall 2017
Your answer
Teacher Name (grade 4-6 only)
Your answer
My child already has a CollegeChoice 529 Account
If your child does not have a CollegeChoice 529, please contact Community Foundation of Wabash County at 260-982-4824 or your student's school to obtain a paper enrollment form.
Required
Promise Scholarship Participant Agreement
The Promise Scholarship Program, developed and administered by the Community Foundation of Wabash County, Inc. (Community Foundation) offers students in grade 4, 6, and 8 the opportunity to earn scholarships to help pay for college and career training after high school. For work accomplished in school – setting goals, turning in assignments, learning about career and college options – students can earn up to $150 in scholarships and savings matches. The Program also offers savings matches for students in grades 5 and 7.

To earn Promise Scholarships and savings matches, parents must agree to participate in the Promise Scholarship Program as follows:

I authorize the Community Foundation, Manchester Community Schools, Metropolitan School District of Wabash County, Wabash City Schools, CollegeChoice529, State of Indiana, Indiana Education Savings Authority, and Ascensus Broker Dealer Services, Inc., including each of their respective affiliates, directors, officers, employees, contractors, representative and agents, (collectively, “Promise Scholarship Program Representatives”) to take photographs, video/audio/sound recordings and interviews (collectively, “Depictions”) of me and/or the minor child listed in this Promise Scholarship Participation Agreement for its lawful use in connection with the Promise Scholarship Program including use in any audio or visual work, marketing materials, print campaigns, posters, commercials, social media, internet sites or any other media (whether now known or hereafter devised) (collectively, “Works”). I hereby assign fully to the Promise Scholarship Program Representatives, all right, title and interest in and to all Depictions and Works, and accordingly grant the Promise Scholarship Program Representatives the right to reproduce, exhibit, display, broadcast and distribute the Works or Depictions, and all derivative works thereof.

AUTHORIZATION FOR RELEASE OF PROTECTED EDUCATIONAL RECORDS: I authorize Manchester Community Schools, Metropolitan School District of Wabash County, and Wabash City Schools to disclose educational records regarding my child, as further described below, for the purpose of my child being eligible to apply for and receive scholarship funds through the Promise Scholarship Program. The name of the person or class of persons authorized to receive the information are employees of the Community Foundation of Wabash County, P.O. Box 7, North Manchester, IN 46962. The following protected educational records, (collectively Minor’s Data) may be disclosed by my child’s school: All educational records, of my child that establish my child has met the academic criteria to be eligible for a scholarship award through the Promise Scholarship Program administered by the Community Foundation of Wabash County. I am authorizing this release relating to my child’s educational records to remain valid through the end of my child’s 8th grade school year.

I hereby release and hold harmless Promise Scholarship Program Representatives from and against any and all losses, claims, penalties, demands, actions, causes of action, damages, complaints, or liability arising out of or related to the use of the Minor’s Data, Works, or Depictions of me and/or the minor child.

I further waive any right to inspect or approve the use of the Depictions or Works or rights to any royalties or other compensation arising from or related to the use of the Depictions or Works, in connection with the use of the Depictions of Works as described above.

I certify that I am the parent or legal guardian of the minor child listed in The Promise Scholarship Participation Agreement. I have read the contents of this waiver and fully understand its contents, meaning and impact and sign it of my own free act and will.

Required
Parent or Guardian Electronic Signature
Your answer
Date
MM
/
DD
/
YYYY
FOR OFFICE USE ONLY
CF ID# _______________________ Scholarship Fund ID#_______________________

Graduation Year_____________

Entered into FIMS _______________ Date______________

Entered into Access________________ Date_______________

Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms