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Scholarship Application

Parent or Guardian Name:

Email:

Phone:

Relationship to Applicant:

Student Name:

Does the youth for which you are filling out this application live with you?

What is the youth’s primary address?

What is the total annual household income (before taxes)?

How many people live in the household, including children and adults?

Are there any government assistance programs that the household is currently receiving (e.g., SNAP, TANF, Medicaid)?

Are there other specific areas of support the youth or family is interested in outside of this program?

academic support (tutoring)

mentorship

sports

mental health

Thank you! We've received your scholarship application and will make determinations based on the amount of scholarship funds available.

You can expect to hear back from us soon regarding the next steps.

The NC EmpowerUP Team

Oops, there was an error sending your message.
Please try again later.

Scholarship Application

Parent or Guardian Name:

Email:

Phone:

Relationship to Applicant:

Student Name:

Does the youth for which you are filling out this application live with you?

What is the youth’s primary address?

What is the total annual household income (before taxes)?

How many people live in the household, including children and adults?

Are there any government assistance programs that the household is currently receiving (e.g., SNAP, TANF, Medicaid)?

Are there other specific areas of support the youth or family is interested in outside of this program?

academic support (tutoring)

mentorship

sports

mental health

Thank you! We've received your scholarship application and will make determinations based on the amount of scholarship funds available.

You can expect to hear back from us soon regarding the next steps.

The NC EmpowerUP Team

Oops, there was an error sending your message.
Please try again later.

Contact Info

500 W. 5th Street, Suite 800 PMB 34

Winston-Salem, NC 27101

Phone: 336.722.6058

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Scholarship Application

Scholarship Application

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