Scholarship Disclaimer Form

RETURN THIS SECTION TO “COA” ALONG WITH YOUR COMPLETED QUESTIONNAIRE

This is to inform you that there are no promises made as to whether you will receive this scholarship or how long it will last. It will all depend on how many applications are approved and how long the funds hold out. The Council On Aging (COA) will be soliciting donations to the Fund and will work hard to keep this benefit going; however, due to circumstance we cannot foresee this may be a limited offer.Initial ________

 
I authorize the Durango/La Plata Senior Center to release my attendance records to the COA, for any of the activities/classes that I receive COA Scholarship monies for.Initial _________

 
I, ______________________________, have read and agree with the above statements and have received a copy for my personal records.
Date________________

Be sure to fill this out and include it with the Scholarship Application Form,

There are several ways to do this without leaving your home.  You may  copy and paste this form into a text document program and print it, fill it out and mail it in.  You may copy, paste and send it to the email address below.  You can click on COA Scholarship Disclaimer Form below to download it and then SAVE it to your computer, fill it out and e-mail it to us at the email address below.

A copy of this form is available in printed form at the Durango – La Plata Senior Center at 2424 Main Ave. in Durango.

laplatacoa@gmail.com

Scholarship Disclaimer Form