Scholarship Application

1Criteria Disclaimer

2Application

3Waiver

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)
*Case worker and parent/guardian need to help provide information to aid PAS in finding an appropriate location
Completed application, signed waiver and criteria checklist
Child must complete the section of the application regarding his/her passion, in their own words
Child must reside in between the Philadelphia and Trenton area
Summer camps are not considered for PAS scholarships

Criteria Acknowledgement*

Yes

I have read and believe that I/my child meet(s) the criteria for consideration of a PAS scholarship.

Student Information

Name*

First Middle Last

Birthdate*

Age*

Gender*

School*

Who do you live with?*

Both Parents

One Parent

Other

If you answered "One Parent" or "Other" in the question above please specify who you live with below.

Parent/Guardian Information

Parent/Guardian Name*

First Last

Home Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Cell Phone

Work Phone

Email*

Referrals

Who referred you to Plant a Seed?*

First Last

Agency

Phone

If you are the caseworker referring this child, please provide any pertinent information that might help PAS determine eligibility as well as ideas for pursuing their passion.*

If you are not a caseworker, please type in Not Applicable.

Household Information

Annual Family Income (estimated gross, all sources, one year)*

You may be asked to provide financial statements

Verification of Income*

Max. file size: 50 MB.

Please upload verification of income, such as a W2. Applications without proof of income will not be processed.

Number of children, under 18 years old, in family*

Have you received a scholarship from PASF before?*

Yes

Can you provide transportation?*

Yes

If you cannot provide transportation, how will you get to the activity?*

If you are able to provide transportation, please type in Not Applicable.

Does the child applying receive a reduced or free school lunch?*

Yes

If there are there any health, educational or financial considerations you would like us to know about, please explain below.*

Tell Us About Yourself

Child must complete this section of the application regarding his/her passion, in their own words.

In your own words, tell us about your one specific passion and what it means to you.*

Are you currently involved in any activities? If yes, please list them.*

We need your help in finding a location where your passion can be supported. Please list at least one location near your home. Please include address, phone number, and if possible, contact person.*

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.

Parent/Guardian Acknowledgement*

I acknowledge that I have read, understand, and agree with the terms above. 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 type Parent/Guardian name*

First Last

Should you have any questions, please contact Michele by emailing Michele@plantaseedfoundation.org or calling 215-630-9657.

Criteria for PAS Request

Student Information

Parent/Guardian Information

Referrals

Household Information

Tell Us About Yourself

RELEASE AND WAIVER OF CLAIMS