PRIVATE AND CONFIDENTIAL

SCHOLARSHIP APPLICATION

PLAYER NAME __________________________________________________________

TEAM NAME ____________________________________________________________

Funding for the ___________________ soccer season.

RESPONSIBLE ADULT

NAME __________________________________________________________________

ADDRESS _______________________________________________________________

Street address City Zip

PHONE NUMBER(S) ______________________________________________________

e-mail ADDRESS _________________________________________________________

ADJUSTED GROSS INCOME _______________________________________________

Please use information from last tax year.

Please attach copy of IRS Form 1040 or equivalent for last tax year.

ADDITIONAL INFORMATION

________________________________________________________________________

If scholarship funding is terminated, the player will be responsible for the remaining fees.

________________________________________________________________________

Responsible Adult Signature Date

All scholarship applicants will be expected to perform some service hours for the club.

Please see the Director for more information.

Please mail to: SSSC, P.O. Box 5275, Beaumont, TX 77726