MEM Scholarship Application

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Please review and complete this form in request tuition assistance for MEM's youth education programs.

Student Name *

Student Date of Birth *

YYYY

Parent/Guardian Name *

Parent/Guardian Email *

Mailing Address *

Household Size *

How many people live in your home, including the student and yourself?

Household Monthly Income *

Example: $1210, $2500 per month. etc

Additional Comments

Please let us know of any special accommodation or needs we should be aware of. We will work to meet those to the best of our ability.

Acknowledgement
*

I confirm that all the above statements are true and accurate to the best of my knowledge.

Required

Submit

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