GHBPA Scholarship Application Form

Student Name: _____________________________ Grade: ____

(Last, First, Middle Init.)

Event: _________________________________ Date: ________

(i.e. Spring Education Seminar, Summer Prep Course) (mm/dd/yy)

This form is for making application for use of appropriated GHBPA Scholarship Program funds and applying them towards the cost of an authorized event. It specifically directs and authorizes the Student Accounts Treasurer to apply any available scholarship credits in awarding of a GHBPA scholarship for that event and to utilize awarded funds on behalf of the student for that purpose. This form must be completed and signed only by the parent/guardian of the student. Scholarship Applications will be accepted anytime up until the published cutoff time for the specific authorized event. Parents who have submitted Student Account Withdrawal Requests for the same event will automatically have any awarded scholarship funds applied prior to utilizing their Student Account funds. Forms must be deposited into the white Student Accounts Box (white metal box mounted on the wall in the band room).

· This form is the only method that will be accepted for application for award of GHBPA appropriated scholarship funds.

· Submission cutoff dates are established and published for each authorized event. Please familiarize yourself with the established cutoff date for your specific authorized event. Forms received after the published cutoff date will not be accepted!

· This form does not replace or serve as a substitution for the Student Account Withdrawal Form and is not related in any way to that program. Students/parents wishing to utilize their Student Account funds must still submit the required forms in compliance with that program’s requirements.

Parent/Guardian: Please read the following acknowledgement, complete form and sign below:

As the legal parent or guardian of the above named student, I hereby acknowledge, understand, and give my consent, for the Student Accounts Treasurer to automatically utilize and apply all available and awarded scholarship funds on behalf of the above named individual student and apply those funds toward the individual costs of the specific authorized event, up to the maximum amount due. Additionally, if the amount of scholarship award differs from the actual individual student costs of the authorized event, then only the lesser of those two amounts will be awarded and applied toward the event costs, with any remaining balance still due.

Parent/Guardian Information:

_______________________________________ __________

(Parent/Guardian Last Name, First Name) (Phone #)

______________________________________ __________

(Parent/Guardian Signature) (Date)

NOTE: Per IRS regulations, the GHBPA Scholarship Program funds cannot be disbursed directly to the student and can only be used for actual individual student authorized event costs. For any additional information, please email the GHSB Student Accounts Treasurer at “ghsb_studentaccts@cox.net”.

Revision 12/04/2007