Scholarship Application

COUNCIL ON AGING (COA) SCHOLARSHIP FUND QUESTIONNAIRE

Current policy of the Scholarship Program asks that an individual’s monthly income be below $2300/month. In some cases exemption of this policy will be considered. Please explain any extenuating circumstances in question #6 below. Examples include, but are not limited to excessive medical bills; housing expenses that are higher than 50% of monthly income and/or care giving expenses for a family member. The idea is that the extenuating circumstance results in not having enough money left over for something extra like classes at the senior center. If you need more room, please use the back of the questionnaire.

DATE: ___________

NAME: ______________________________MARITAL STATUS________

ADDRESS: __________________________________________________

PHONE(S): __________________________________________________

EMAIL: _____________________________________________________

CONTACT INFORMATION IN CASE OF EMERGENCY:

___________________________________________________________

___________________________________________________________

ANNUAL INCOME FOR YOU AND/OR YOUR SPOUSE:

___________________________________________________________

1. Reason you are applying to the Council On Aging (COA) Scholarship Fund:

___________________________________________________________

___________________________________________________________

2. Which class/activity are you seeking assistance for at the Senior Center? PLEASE CIRCLE ONE from the
following list of ACTIVITIES AND CLASSES ELIGIBLE FOR SCHOLARSHIP FUND ASSISTANCE:

WATCH YOUR STEP (WYS) LINE DANCING
ZUMBA DOG TRAINING
TAI CHI COMPUTER CLASS
YOGA

3. Is your need for assistance short term or long term?

__________________________________________________________

4. Is your need for a partial or full Scholarship? If for a partial scholarship, how much assistance are you seeking?

___________________________________________________________

5. Are you currently qualified for any subsidized or assistance program such as housing, Medicaid or SNAP?
Which one(s)?

____________________________________________________________

____________________________________________________________

____________________________________________________________

6. Other information you wish us to know:

____________________________________________________________

____________________________________________________________

____________________________________________________________
Approval by Scholarship Committee: DATE: _______________YES____NO____

REASON:_____________________________________________________

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 Application 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

COA Scholarship Application Form