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Child's Name (required)

Activity

Arts and Educational:

Please Specify:

OR

Sports:

Please Specify:

Tell us Your Story

 Yes! O4K may publish my story! No Thank You
* By allowing O4K to publish your personal details, you will help inspire other children to realize the opportunities available to them through our sponsorship program. If you choose no, we will be sure to leave out any personal specifics when publicizing a scholarship granted.

School

Team/Club Name

Coach/Teacher Name

Coach/Teacher Contact Information (email or phone)

Amount Requested

Date Needed By

Please answer the following questions to help us identify your financial status. These questions alone will not solely determine scholarship.

My household receives Temporary Assistance for Needy Families (TANF).
 Yes No

My household receives WIC, Cash Assistance or any other state government assistance.
 Yes No

My household income is less than 150% of the federal poverty level. (Please CLICK HERE for a link to the federal poverty guidelines. Based off of how many in your household, locate guideline amount and multiply by 1.5. Do you fall below this?)
 Yes No

The child requesting scholarship is Chronically ill? Chronically ill is defined as someone who is not terminally Ill, but has been certified within the previous 12 months by a licensed health care practitioner meeting the following requirements;
1. Person is unable to perform (without substantial help) at least two activities of daily living for a period of 90 days or more because of a loss of functional capacity.
2. The person requires substantial supervision to protect himself or herself from threats to health and safety due to severe cognitive impairment.

 Yes No

The child requesting scholarship is Physically Disabled. This is defined as an individual with a physical impairment that substantially limits one or more major life activities ( examples are seeing, hearing, breathing, communicating, working, walking, etc.)
 Yes No

Please Upload Proof of Need

Date of Birth