IMPACT Bay Area Scholarship Application
Thank you for your interest in taking an IMPACT class! We look forward to receiving your scholarship application. We will review your application and be in touch within two weeks. If you have any questions or do not hear from us, please contact us at
Sign in to Google to save your progress. Learn more
Email *
Applicant Contact Information
Applicant's Full Name *
Applicant's Preferred Name (optional)
City *
ZIP Code *
Primary Phone Number *
What's the best way to contact you?
Please check here if you are a parent or legal guardian applying on behalf of your child.
Demographic Information
Information shared will not affect our selection process. It assists us in grant reporting and increases our understanding of the populations we serve.
Date of Birth *
Age *
Gender *
Sexual Orientation
Ethnicity or Race *
Number of People in your Household *
Monthly Gross Income *
Main Source of Income *
More Detail Information
We recognize that an applicant may have a higher level of income, yet still be in a situation which makes it extremely difficult for them to afford an IMPACT class without scholarship assistance. If this describes you, please explain why you need a scholarship. *
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 or fears, referral by therapist or victim advocate, etc.). *
Class Preference and Co-Pay
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/LGBTQ/Young Adult Basics (reg. approx. $650) Scholarship Sliding Co-Pay Range: $50-$500
• Teen Course (reg. $300) Scholarship Sliding Co-Pay Range: $50-$200
• 3-Hour Intro Class (reg. $85) Scholarship Sliding Co-Pay Range: $30-$75
First Choice Class *
Please Select your first choice class type
First Choice Class Date (Or start of Course)
First-Choice Co-Pay
Second Choice Class (optional)
Please Select your second choice class type
Second Choice Class Date (Or start of Course)
Second-Choice Co-Pay
Testimonials from our scholarship recipients are an important part of our ability to raise money to provide assistance for others. If awarded a scholarship, you agree that after you take the class or your course 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 in online and print media for promotional and fundraising purposes.

Please add your name and date below, thus confirming that the information you have provided in this application is true and correct.
Name *
Today's Date *
A copy of your responses will be emailed to the address you provided.
Clear form
Never submit passwords through Google Forms.
This form was created inside of Impact Bay Area. Report Abuse