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Name*
First Last
Address*
Street Address City State ZIP Code
Email*
Phone*
Birthdate*
MM slash DD slash YYYY

Injured or Deceased Parent
Injured or Deceased?*
- Injured
- Deceased
Name*
First Last
Employer*
Social Security Number*
WCC Claim Number
Date of Injury*
MM slash DD slash YYYY
Date of Death*
MM slash DD slash YYYY
Parent/Guardian
Name*
First Last
Address*
Street Address City State ZIP Code
Email*
Phone*
Employer
Work Phone

School Planning to Attend
Name of School*
Location*
City State
Application Submitted*
- Yes
- No
Enrollment Acceptance*
- Yes
- No
List any special circumstances the Board of Directors should be aware of when considering your application

Estimated Family Contribution
How much will the family be providing for the applicant’s schooling costs?
GPA
Unmet Need
Difference between the costs and the amount of available funds.
Total Official Cost of Attendance
Total Financial Aid Package being offered (EXCLUDING any loans to be repaid)
Paragraph explaining why this student should be awarded

Student Media Release and Consent Form
I hereby give my consent to Kids’ Chance of Arkansas, and its representatives and authorized media organizations, permission to photograph, videotape, and/or voice record me, and that my name, image, likeness and voice may be used in Kids’ Chance of Arkansas approved photographs, videos, publications, internet, news and social media and web pages for special projects and publicity.

I am also fully aware that I will not receive any monetary compensation for the rights granted herein. I further release and agree to hold harmless Kids’ Chance of Arkansas, its Board of Directors and any other representatives, from all claims, demands, and liabilities whatsoever in connection with the rights granted herein. I have reviewed this document with my parent/guardian and their signature below reflects their agreement with all of the terms and conditions of this Release and Consent Form.

Throughout the year, students may be highlighted in efforts to promote Kids’ Chance of Arkansas activities and achievements. I hereby give consent to use my name and likeness/my child’s name and likeness to advance the charity’s purpose and reporting requirements. This includes information to prospective donor groups and individuals to further the goals of Kids’ Chance of Arkansas.

I certify that I have read the Student Media Release and Consent Form and fully understand its terms and conditions.
Signature of Parent/Guardian*
Signature of Applicant*

Injured or Deceased Parent

Parent/Guardian

School Planning to Attend

Student Media Release and Consent Form

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