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.
NAME: ______________________________MARITAL STATUS________
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
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?
6. Other information you wish us to know:
Approval by Scholarship Committee: DATE: _______________YES____NO____
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.