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2023-2024 Trailblazer Scholarship Application


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Thank you for your interest in applying for the 2023-2024 Trailblazer Scholarship Program. You can register for the scholarship at any same time and there is no deadline for an application. It is a one time application and must only be filled out again if you add a Trailblazer to your family. Scholarships are made possible by our community partners and donors, and are available on a first come first serve basis.

A Scholarship is limited to one Adventure Experience a month per child in your home. Please call Trailblazing Hope Outdoors at (937) 802-0801 with any questions or for more information, or email info@trailblazinghope.com with Trailblazer Scholarship in the subject line.

Eligibility:

100% Scholarship: If your child or your family receives free lunch at school, or assistance from SNAP, TANF, MFIP, WIC, SSI, Section 8 housing, Medical Assistance or Medicaid your Trailblazer is eligible for a 100% scholarship.

Please check the program your family participates in below under eligibility and sign the form.

50% Scholarship: If your child or your family receives reduced lunch or is at or near the Federal Poverty Guidelines your Trailblazer is eligible for a 50% scholarship.

Confidentiality:

All information provided is kept confidential and private. There will be no authorized dissemination of financial or personal information without applicants consent.
Eligibility
Select all programs your family is enrolled in: *
TANF
MFIP
WIC
SNAP
Section 8 Housing
SSI
Free/Reduced Lunch Program
Medicaid
How many children in your household? *
1
2
3
4
5+
Select Annual Gross Household Income Level
$0-$15,000
$15,000-$20,000
$20,000-$30,000
$30,000-$50,000
$50,000-$75,000
First Parent/Guardian Name

First Name*

Middle Name

Last Name*

Phone*
First Parent/Guardian Date of Birth*
I certify that I am 18 years of age or older
First Parent/Guardian Signature*
Second Parent/Guardian Name

First Name*

Middle Name

Last Name*
Second Parent/Guardian Date of Birth*
Third Parent/Guardian Name

First Name*

Middle Name

Last Name*
Third Parent/Guardian Date of Birth*
Fourth Parent/Guardian Name

First Name*

Middle Name

Last Name*
Fourth Parent/Guardian Date of Birth*
Fifth Parent/Guardian Name

First Name*

Middle Name

Last Name*
Fifth Parent/Guardian Date of Birth*
Sixth Parent/Guardian Name

First Name*

Middle Name

Last Name*
Sixth Parent/Guardian Date of Birth*
Seventh Parent/Guardian Name

First Name*

Middle Name

Last Name*
Seventh Parent/Guardian Date of Birth*
Eighth Parent/Guardian Name

First Name*

Middle Name

Last Name*
Eighth Parent/Guardian Date of Birth*
Ninth Parent/Guardian Name

First Name*

Middle Name

Last Name*
Ninth Parent/Guardian Date of Birth*
Tenth Parent/Guardian Name

First Name*

Middle Name

Last Name*
Tenth Parent/Guardian Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
Parent/Guardian Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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