Tuition Assistance Request Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Please fill this form out completely in order to be considered for a scholarship with The Kiva Center programs.

Email *

Parent's Name: *

Parent's Email: *

Phone Number: *

Address: *

Please specify your race: *

American Indian or Alaskan Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Prefer not to answer

Other:

Please specify your Ethnicity: *

Hispanic or Latino

Not Hispanic or Latino

Prefer not to answer

Marital Status:

Married

Single

Divorced or Separated

Widowed

Other:

Clear selection

Occupation: Please list occupations of everyone earning an income in your household *

Child's Name: *

Which program are you requesting a scholarship for? (Please provide the name of the group and start date of the program). *

What is the cost of the program for which you are requesting a scholarship? Please note, if the program has a sliding scale cost put the low-end amount here. *

Is your child(ren) eligible for CHE funding? Please reference our website for more information

Yes

I'm unsure

Other:

Clear selection

Please select the scholarship tier you are requesting: *

Tier 1 – Base (customary) scholarship: 20-30% off low-end sliding scale amount

Tier 2- Mid-Range (substantial) scholarship: 50% off low-end sliding scale amount

Tier 3 – Peak (compelling need) scholarship: 70-100% off low-end sliding scale amount

Other:

Tell us about your child and how their learning style. What type of learning environment do they thrive best in? *

Tell us why this is an important time in your life to enroll your child(ren) in this program. In other words, how do you feel this program will support your child(ren) in their wholeness and development? *

If your family has participated in programs with The Kiva Center before, tell us a bit about how you benefited from the program, and something about the way you and your child(ren) integrated the experience into your life. *

Why is it that you are currently in the position of requiring financial aid at the tier level you have chosen? No apologies necessary - just tell us about your current situation. For example, if you are not employed now or have not been for some time, why not? What are your future financial plans? Include anything that might help us understand your need for financial assistance, and the scholarship tier you’ve chosen. *

Clear form

Never submit passwords through Google Forms.

This form was created inside of The Kiva Center.

Does this form look suspicious? Report

Forms