Renewal Application - April 2015 1 Scholarship Application2 Recipient Response3 Parent Response4 Waiver5 Criteria6 Sign and Complete Student InformationName* First Last Birthdate* Date Format: MM slash DD slash YYYY Age*Gender*MaleFemaleSchool*Parent/Guardian InformationName* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home Phone*Cell PhoneWork PhoneEmail* Who do you live with?*Both ParentsIf living with only one parent, please choose "Other" and specify whichNumber of children in household*Can you provide transportation?*YesNoHousehold InformationAnnual Family Income (estimated gross, all sources, one year)*You may be asked to provide financial statementsVerificaiton of Income*Please upload verification of income, such as a W2. Applications without proof of income will not be processed.Does your child receive reduced/free lunch?*YesNoHave you received a scholarship from PASF before?*YesNoReferralsWho referred you to Plant a Seed?* First Last Email AgencyPhoneHow did you hear about us?*Please ask your caseworker to provide any information that will aid us in helping your child.*By signing on the last page of this application, I certify that all preceding information is true AND that I will never use this activity as a form of reward or punishment. I have transportation and will make a commitment that my child will attend this activity on a consistent basis. How has PAS helped your child pursue his/her passion? Please describe what it has meant to him/her.*Please explain your current situation and financial need?*How has your child’s instructor impacted his/her life?*Is there anything else you’d like to share that will help us make a determination to renew your child’s scholarship?* Please describe your passion and how PAS has helped you pursue it. What has this meant to you?*How has your instructor or mentor impacted your life?*Is there anything else you’d like to share that will help us make a determination to renew your scholarship?* RELEASE AND WAIVER OF CLAIMS For and in consideration of funding received from Plant A Seed Foundation, Inc., I the undersigned, as parent and/or natural guardian of the below named minor child, do hereby agree as follows: Whereas the undersigned desires to participate in and accept funding from Plant A Seed Foundation, Inc., as a charitable endeavor sponsored by Plant A Seed Foundation, Inc., I understand and agree that Plant A Seed Foundation, Inc. and all of its affiliates including, but not limited to sponsors, vendors, volunteers and staff (hereinafter collectively referred to as "Plant A Seed Foundation") shall not be responsible or legally liable for any losses of personal property, or any bodily injury or the result thereof, incurred and suffered by us as the result of any property, equipment and/or service arranged for and funded by the Plant A Seed Foundation. As a further condition of our participation, we further agree to forever remise, release, discharge and hold harmless Plant A Seed Foundation for any and all claims at law or equity that I or my heirs, successors and/or assigns shall now have, ever had or will have stemming from any activity and/or equipment paid for by Plant A Seed Foundation until the end of time. Additionally, we agree to indemnify and hold harmless Plant a Seed Foundation (including but not limited to sponsors, vendors, volunteers and staff) for any damage, loss of personal property and/ or bodily injury resulting from any acts, during any activity and/or equipment paid for by Plant A Seed Foundation. By signing below, the undersigned acknowledges and fully understands that he/she will be engaging in activities that may involve risk of injury, perhaps serious in nature and including permanent disability and death which might result not only from their own actions, inactions or negligence, but the action, inaction or negligence of others, from the conditions of the premises and/or any of the equipment used. Further that there may be other risks not known to us or not reasonably foreseeable at this time; I/We assume all the foregoing risks and accept personal responsibility for the damages following such injury, permanent disability or death. I have read this release carefully before signing. I have signed this document voluntarily and with full knowledge and understanding of the contents of the Release. I further give my consent for Plant A Seed Foundation to use any photographs of me during any activity. Waiver Acknowledgement* I certify that I agree to the above terms of the waiver Criteria for PAS Request Strong passion in a specific area of interest Child must be between the ages of 10 and 18 Financial need Limited involvement in activities outside of school Must be able to provide transportation Must demonstrate commitment (i.e. return phone calls in a timely fashion, furnish necessary documentation, consistent attendance in regard to the activity) Completed application, signed waiver and criteria checklist Child must complete the section of the application regarding his/her passion, in their own words Summer camps are not considered for PAS scholarships Criteria Acknowledgement* I have read and believe that I/my child meet(s) the criteria for consideration of a PAS scholarship. Certification I certify that all preceding information is true AND that I will never use this activity as a form of reward or punishment. I have transportation and will make a commitment that my child will attend this activity on a consistent basis. Signature of Parent/Guardian*Please print Parent/Guardian name* First Last
