Applicant's Name *

First Name

Last Name

Phone

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Applicant's birthdate *

MM

DD

YYYY

Parent or Guardian Name *

First Name

Last Name

Parent or Guardian Phone *

(###)

###

####

Parent or Guardian Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

I agree to provide qualifying documents in the form of your child's Medicaid, SNAP, or WIC letter, screenshot, or image verifying your child is a beneficiary of Medicaid, SNAP, or WIC should your child be selected as a scholarship recipient. This document must include your child's name and active dates within 12 months of the current date.

I agree

Season start date *

MM

DD

YYYY

Season end date *

MM

DD

YYYY

Contact at organization *

Please provide the contact at the organization that can confirm that the season is moving forward and can verify athlete's participation.

First Name

Last Name

Contact's Phone *

(###)

###

####