AccessEd Scholarship Application 20-2021
Student Name *
First and last name
School Year
Application Date *
MM
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DD
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YYYY
What has you worried?
Please share your concerns about your student's situation.
How much can you contribute towards a tutoring session per month?
Use the family contribution calculator to figure out your monthly contribution. Click here to start: http://accessedfoundation.org/family-contribution-calculator/ , then enter the MONTHLY FAMILY CONTRIBUTION amount below. We will discuss the details during the intake meeting
How many in your household? *
Student Information
Birthdate *
Please enter your student's correct birth year and not this year.
MM
/
DD
/
YYYY
School *
What school does the student currently attend?
If your student attends a private or parochial school, how much financial aide do you receive?
Clear selection
Grade Level *
What grade will your child be in the Fall of 2020?
Special Ed *
Does your child have a 504 plan or an IEP?
How did you hear about us?
Clear selection
Parent/Guardian Information
Parent/Guardian Name *
First and last name
Address *
City *
ZIP Code *
Phone *
Email *
Additional Parent / Guardian Information (optional)
Parent/Guardian Name 2
First and last name
Address 2
Include city, state and ZIP
Phone 2
Email 2
Submit
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