Date
Student's Name
Student Number
Local Address(street, city,state,zip)
Parents' Name
Permanent Address (Street,city,state,zip)
Student Phone(Local)
Home Phone
E-Mail
Requesting Scholarship For:	Fall Spring Summer
Amount Requested
Major
Current G.P.A.
How long have you participated in H.E.L.P.?
If you receive a Pell Grant, What is the amount per year?
Provide information for any additional Grants and Finincial Assistance, including grant name and amount.
If you recieve rehabilitation services, what amount do they provide?
If you are currently employed, where do you work and what is your salary
In the space below (and the back) indicate why you feel you need and qualify for a fee waiver with H.E.L.P.