Scholarship Application

Student Information

Name*

First Last

Birthdate*

Age*

Gender*

T-shirt Size*

Please let us know what size t-shirt the applicant wears. We will send a PAS t-shirt to your home just for them once approved!

School*

Tell Us About Yourself

Please have the application fill out this section to the best of his/her ability. If the application is unable, parent/gaurdian may fill in sections as applicant verbalizes answers.

What is your favorite subject in school?*

If you had to eat one food everyday, what would it be?*

What is your favorite activity to do after school?*

Who is your hero?*

If you could have one superpower what would it be?*

Parent/Guardian Information

Name*

First Last

Address*

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

Home Phone*

Cell Phone

Work Phone

Email*

Who do you live with?*

Both Parents

Other

If living with only one parent, please choose "Other" and specify which

Referrals

Who referred you to Plant a Seed?*

First Last

Email

Agency

Phone

How did you hear about us?*

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.*

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

No

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

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.*

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.

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.

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

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

Yes

Signature of Parent/Guardian*

Please print Parent/Guardian name*

First Last

Criteria for Scholarship

Student Information

Tell Us About Yourself

Parent/Guardian Information

Referrals

Household Information

RELEASE AND WAIVER OF CLAIMS

Criteria for PAS Request