Extreme Journey Scholarship Application

Student Name*

First

Last
Parent Name*

First

Last
Email*
Phone*
Address*

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country
Which session are you registering your student for?*
- Session 1
- Session 2
- Session 3
Household income (gross annual income)*
Household size (number of adults and children)
Please explain the reason for scholarship request, and any special circumstances that should be considered.*
What amount of scholarship are you requesting?*
- Half scholarship ($225 per session registered for)
- Full scholarship ($450 per session registered for)
Number
Number