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Scholarship Application

Parent/Guardian Name (You):______

Child’s Name: ______

Full Name Date of Birth

Applying for the following grade: ______

AgreementtoParticipate

Insubmittingthisapplication,Iagreetothefollowingforeachchild

namedonthisapplication:

  • Iunderstandthattobeeligibleforascholarship with SavannahHonorAcademy, Imustmeetcertainincomeguidelines.
  • Iunderstandthatifthere are more applications received than open spots,mychild’snamewillbeplacedinalotteryfora scholarship.Ialso understandmychild(ren)mayormaynotreceiveascholarship underthisprogram.
  • I understand that SavannahHonorAcademy must keep copies of all documentation submitted during the application process to ensure that families are eligible. The school will keep this data strictly confidential.
  • I understand that SavannahHonorAcademy will not release to anyone or any organization personally identifiable information in this application, except as required by law.
  • I understand that SavannahHonorAcademy reserves the right, at any time, to terminate enrollment of any student or family who disrupts the learning community or fails to follow the rules and regulations set forth in the Family/Student Handbook.

______

Parent/Guardian Signature Date

Parent/Guardian Parent/Guardian

Name: ______

Relation: ______

(mother, father, grandmother, etc.)

Address: ______

______

(if different than above) (if different than above)

Cell #:______

Work #: ______

Occupation: ______

Employer: ______

E-mail: ______

Parents are (check one): married_____ divorced _____ separated_____ partners____

Other important adults (additional parental figures or guardians):

Name: ______Relation:______

#______e-mail:______

Name: ______Relation:______

#______e-mail:______

In case of separation or divorce:

Who should receive correspondence?

Mother _____ Father______Both______Other:______

Who has legal custody of the child?

Mother _____ Father______Both______Other:______

Who will assume financial responsibility for the child?

Mother _____ Father______Both______Other:______

Siblings:

Name(s): Age(s):

______

______

PresentSchool Information (if applicable):

School Name______

Address: ______

Phone #: ______

Has the child been enrolled or tutored in a special program? Yes_____ No______

(gifted, resource, learning difference)

If yes, which program?______

Does the student have any medical or physical conditions Yes_____ No______

that may limit or affect regular school work or participation

in activities at school?

If yes, please explain: ______

______

Allergies:______

Does the student have any current or history of behavioral or emotional problems that may affect his/her work? Yes_____ No______

If yes, please explain:______

______

______

Has the child ever been suspended or expelled? Yes______No______

If yes, please explain: ______

______

______

Interest in SavannahHonorAcademy:

How did you first learn about SHA?

Friend:_____ Family Member:_____ Internet Search:_____ Preschool:_____

SouthernMamas.com:_____ Other:______

Key factors influencing your application to SHA:

Class Size_____ Teachers_____ Location_____ Facilities_____ Curriculum_____ Other:______

Demographics (optional)

Student’s Ethnicity: _____African American ____Asian _____ Caucasian

____Hispanic ____Middle Eastern ____Multi-racial _____ Native American

Other:______

Religious Preference: _____Buddhist _____Christian _____Hindu _____Jewish

_____Muslim Other:______

Image Use

I understand that my child may be included in photographs, videos, audiotapes, or other recordings to be used for school and general promotional purposes, including but not limited to the SHA website and brochures. I give the SHA administration permission to use such photographs, videos, or other recordings of my child for purposes of promoting the school as it may see fit.

______Yes ______No

(A blank response will be interpreted as a yes)

Residency & Contact Information

Parent/Guardian Name (you): ______

Home Address: ______

______

City State Zip Code

Home Phone: ______Work Phone:______

Cell Phone:______E-mail:______

Current Residence Information

How many people live in your residence? __1__ + ______+ ______= ______

You # Other Adults # Children Total

(18 & older) (17 & younger)

What is your monthly rent or mortgage?

 Rent $______ Mortgage $______ Other $______

Who pays your monthly rent or mortgage?

 You(Parent/Guardian)  Non-governmentorganization

 Spouse Government Agency

 Otheradult(resideswithyou)  Otheradult(doesnotresidewithyou)

 Other:______

Checkifanyofthefollowingapply:

 Livewithfriendorrelative(otherthanminorchildren)

 Livewithroommateorhousemate

Name of Student / Student 1
______ / Student 2
______
Social Security # / ______-______-______/ ______-______-______
Date of Birth / / / / / /
Gender / ____ Female ____ Male / ____ Female ____ Male
Relationship to You / _____ Daughter/Son
_____ Grandchild
_____ Foster Child
_____ Niece/Nephew
Other:______/ _____ Daughter/Son
_____ Grandchild
_____ Foster Child
_____ Niece/Nephew
Other:______
Current Grade
CurrentSchool Name / ______/ ______
CurrentSchool Type / _____ Public School
_____ CharterSchool
_____ Private School
_____ HomeSchool
_____ Daycare/Preschool / _____ Public School
_____ CharterSchool
_____ Private School
_____ HomeSchool
_____ Daycare/Preschool
Does the student have any of the following challenges? / _____ Physical Disability
_____ Learning Disability
_____ English Language
_____ IEP / _____ Physical Disability
_____ Learning Disability
_____ English Language
_____ IEP
First Language: / _____ English
Other: ______/ _____ English
Other:______
Student’s Race/Ethnicity
(Only used for statistical purposes) / Black,African American
White Hispanic Asian
 Native Hawaiian/Pacific Islander  Bi-racial
Other:______/ Black,African American
White Hispanic Asian
 Native Hawaiian/Pacific Islander  Bi-racial
Other:______

Information for Parent/Guardian and Additional Adults

Name / You
______/ Adult 2
______/ Adult 3
______
Relationship to You / Self / Spouse
Parent/Step-Parent
Boyfriend/Girlfriend
Son/Daughter(18+)
Grandparent
Other:______ / Spouse
Parent/Step-Parent
Boyfriend/Girlfriend
Son/Daughter(18+)
Grandparent
Other:______
Social Security # / _____-___-______/ _____-___-______/ _____-___-______
Date of Birth / / / / / / / / /
Gender / ___Female ____Male / ____ Female ____ Male / ____ Female ____ Male
Marital Status / Single,nevermarried
MarriedDate:_____
WidowedDate:____
DivorcedDate:____
SeparatedDate:____ / Single,nevermarried
Married,Date:______
Widowed,Date:______
Divorced,Date:______
Separated,Date:______/ Single,nevermarried
Married,Date:______
Widowed,Date:______
Divorced,Date:______
Separated,Date:______
Currently has a job? / ___ Yes (full-time)
___ Yes (part-time)
___ No / ___ Yes (full-time)
___ Yes (part-time)
___ No / ___ Yes (full-time)
___ Yes (part-time)
___ No
Filed Tax Return / ___ Yes ___ No / ___ Yes ___ No / ___ Yes ___ No
NOT required to file tax return / ___ Yes ___ No / ___ Yes ___ No / ___ Yes ___ No

Are you or the children you are applying for currently receiving Food Stamps or TANF?

______Yes ______No

Do you have any dependent children in college? ______Yes _____ No

If yes, what is your total annual contribution for tuition? $______

Income (Annual)

Income Sources / You / Adult 2 / Adult 3
Wages / $ / $ / $
Self Employment / $ / $ / $
Public Assistance / $ / $ / $
Child Support / $ / $ / $
Alimony / $ / $ / $
Interest/Dividends / $ / $ / $
Social Security / $ / $ / $
Disability (SSI) / $ / $ / $
Gifts from Others / $ / $ / $
Other:______/ $ / $ / $

Total Annual Household Income: $______

(Please add all amounts listed in the above table)

Todetermineeligibility,youarerequiredtoprovideofficialdocumentationwith

2013annualincomeamounts.

Assets

Cash
Checking +
Savings +
Net Worth of Investments +
(if negative, write zero)
Net Worth of Business or Farm
(if negative, write zero) +

Total: $______

Expenses (Monthly)

Rent/Mortgage / $
Property Taxes/Insurance / $
Cable/Satellite / $
Telephone/Internet / $
Cell Phone / $
Water / $
Electric / $
Gas/Oil / $
Car payment / $
Car Insurance / $
Transportation (bus, fuel) / $
Health Insurance / $
Other Loan Payments / $
Child Care / $
Food / $
Lessons, Camp fees, Tutoring / $
Other / $

Total Monthly Expenses: $______

Federal and State Taxes paid last year: $ ______

(If you did not pay taxes or received a refund, write zero)

Todetermineeligibility,youarerequiredtoprovideofficialdocumentationwith

monthly expenseamounts.

Parent/Guardian Pledge

I attest that the information provided in this application for enrollment is true and accurate. I understand that if any information is found to be false or misleading, the application process may be terminated or the applicant may be dismissed from SavannahHonorAcademy.

Signed______Date______

(Parent/Guardian)

Signed______Date______

(Parent/Guardian)

Please complete and return this application to 5111 Abercorn Street, 31401.

Upon review and acceptance, we will ask for a nonrefundable $75.00 deposit, which will secure your spot and go towards the first month’s tuition.

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Savannah Honor Academy, Inc. admits students of any race, color, national and ethnic origin to all the rights privileges, programs, and activities generally accorded or made available to students at the school. It does not discriminate on the basis of race, color, national and ethnic origin in administration of its educational policies, admissions policies, scholarship programs, and athletic and other school-administered programs.