The Jason Cunningham Financial Aid Award.pdf

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Application Identifying Information
(Please print clearly or type and review for accuracy an incorrect address will delay or possibly negate any award)

Applicant (child) Name (First, MI, Last): ____________________________________
Child’s Date of Birth (MM/DD/YYYY): ______________________________________
Child’s Gender: _____________________________
Parent/Legal Guardian Name (First, Last): _______________________________________
Relationship to child: ________________ Legal Guardian: ___________________________
Mailing Address: ____________________________________________________________
Email Address: _______________________________________________________________
(An email address is required for us to notify you of the status of your application. If you do not have an email
address, you may provide the email address of a friend, family member, or professional who is willing to help.)

Has the applicant received any other financial assistance towards tuition? ___________________
Financial aid amount? _________________________________
How much do you think you can afford to pay towards your child’s tuition annually? _____________
Application Information (Please type or print clearly)
Does the applicant utilize hearing aids or cochlear implants? _________________________________
If yes, age at which he or she received them? _____________________________________________
What method(s) of communication is used with your child at home and in therapy?
Check all that apply.
_____Listening and Spoken Language
_____Sign Language System (ASL, Signed English, Finger Spelling, etc.)
_____Other, please briefly describe: ____________________________________________________
Please tell us where your child is presently receiving services for their hearing loss: