Scholarship Form : Parent Portal : Boys & Girls Club of Poplar Bluff

It is the policy of Boys & Girls Club to provide services regardless of the inability to pay. Scholarships are offered based on family/household size and annual income. Scholarships DO NOT begin until Administration Approval. Please complete the following information and submit it if you or members of your family are eligible for a scholarship.

Number of Persons living in your household

Below, please list income from ALL sources including gross wages, tips, social security, disability, pensions, annuities, veteran's payment, net business, or self-employment, alimony, child support, military, unemployment, and public aid.

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Household Member

First Name *

Last Name *

Self

Current Monthly Income

Current Annual Income

Household Member

First Name *

Last Name

Spouse/Other Adult

Current Monthly Income

Current Annual Income

Dependent Children under 18

Current Monthly Income

Current Annual Income

TOTAL

Monthly Income

TOTAL

Annual Income

I certify that the family size and income information shown above is correct. Applicant must provide a copy of their latest tax return for documentation and scholarship approval.

Please upload your most recent tax returns

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Please list names of all children applying for BGC membership

Reasons why a scholarship is needed:

Parent/Guardian Name submitting application:

Boys & Girls Club Scholarship