Scholar Within Scholarship Application Name First Last Email PhoneLast Year's Verifiable Household Income: < $35,000 $35,000 – $50,0000 $50,000 – $75,000 $75,000 – $125,000 > $125,000 How many children do you have? 1 Child 2 Children 3 Children 4 Children 5 Children Family Information I am on active duty or a veteran I am a homeschooler I have a special needs student I am enrolled in a charter school I do not have funding from my state to help with my child’s education I do not have funding from my child’s charter school to help with their education Special Needs Information ADHD Dyslexia Autism (ASD) 504 / IEP Auditory Processing Disorder (APD) Visual Processing Disorder (VPD) Visual Impairment Hearing Impairment Down Syndrome What Program(s) Are You Interested In? Reading and Spelling Program Spelling Program Reading Fluency Training Program Summer Reading Program What can you afford per month for the above program(s) in total?$10 – $15/mo$15 – $20/mo$25 – $30/mo$30 – $35/mo$35 – $40/moAre you open to sharing photos or videos of your kids doing the program that we can share on our website, email marketing, paid social, etc.? Yes No Note: No names will be used with the photos or videos.When it comes to your child's reading and spelling education, what do you struggle the most with?Tell us about your children:Is there anything else we should know? Δ
