Somerville Y Scholarship Application

Please fill out our Scholarship Application below.

Scholarship recipients who have done well under this program are those who have:

• Been willing to help others that may be in need.

• Picking up things left out of place.

• Respect for yourself and others.

• Refrained from use of offensive language.

Name *

First

Last

Phone *

Address *

Address Line 1

Address Line 2

City

--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Email *

Secondary Phone

Are you Applying as an individual or Family/Household *IndividualFamily Household

How Many Other Adults? *NoneOneTwoThreeFour

The Names of the Other Adults in the Household (1 name Per line Please) *

How many Children/Dependents *NoneOneTwoThreeFourFive or More

The Names and Ages of the Children/Dependent(s) in the Household *

Parent/Guardian #1: *

• At Home
• Working
• In School

Parent/Guardian #2 *

• At Home
• Working
• In School

Who has custody of the children *

• Joint
• Mom
• Dad
• Guardian
• Foster

Check all Memberships/Programs you are applying for *

• Youth Membership (6-13)
• High School Membership (14-18)
• Adult Membership
• Family Membership
• Child Care or Summer Program
• Other

Please Specify Other: *

To Qualify, We need one of the Following:

Federal Tax Form from the Last Year *

• 1040 Tax Form for Individual or all household incomes
• Filed Jointly, Submitting One 1040
• Filed more than one tax form and we are providing Multiple 1040 forms
• I did not File last year/my household income has changed, submitting documents for last 30 days of Income

1040 or Income Documents *

Click or drag files to this area to upload. You can upload up to 10 files.

Signature *

Clear Signature

Submit