Genesee Home

Genesee Home

Scholarship Application Form

It is our desire that all those who want to participate in the Genesee Home experience have the opportunity to do so regardless of their financial position.

Therefore, for individuals who require some financial assistance, the Genesee Home Board has established an annual scholarship budget to supplement the cost of visiting Genesee Home. The Board has also established the policy that scholarships will only be approved for no more than half (50%) of the current guest fee.

We encourage anyone who has a need for assistance to request a scholarship when completing their request for a visit.

Please read the following carefully before completing and submitting this application:

All requests for scholarships will be reviewed by the Scholarship Committee of the Board of Trustees. The process will take approximately 2 weeks from receipt of a completed request form.
We request a potential recipient first go to their church for financial aid before he/she requests a scholarship.
The Scholarship is a gift and not a loan. A recipient is not obligated to return or "pay back" any financial assistance provided. A recipient may donate money to Genesee Home at some later date if he/she desires.

GENESEE HOME
APPLICATION FOR SCHOLARSHIP

PERSONAL INFORMATION:

First Name: *required fields Last Name: *
Address:
City: State: Zip Code:
Work phone: Home phone:
Cell phone:
Email: *
The best time to reach me is:
Male Female
Birthdate: (Mo./Day/Year): / / (00/00/0000)

REQUEST:

Amount of Scholarship Requested: $ *

Please summarize the reason for your scholarship request (be specific):

CHURCH/MINISTRY AFFILIATION:

Denomination:
Your Position:
Church Name:
Address:
City: State: Zip Code:
Church Phone: Email:

Who referred you to Genesee Home?
Name:
Phone:

FAMILY

Marital Status:
Single Engaged Married Separated Divorced Widowed
Spouse's Name:
Birthdate (Mo./Day/Year): / / (00/00/0000)
Number of Children living at home:

ASSISTANCE

Have you previously applied for a Scholarship from Genesee Home?
Yes No
If yes when:

Have you contacted your church regarding your desire to visit Genesee Home?
Yes No
Are they able/willing to help? Yes No
If NO, please explain why.

Please have a member of your Church Board acknowledge inability to provide financial assistance by email or letter to Charley Blom, Ministry Director of Genesee Home.

EMPLOYMENT HISTORY

Present Employer:
Employment Date: From to
Employer Phone:

If Employer's Address is different from Church Address please fill in below:
Address:
City: State: Zip:

Job Description:

INCOME

My monthly income: $
My spouse's income: $
Other Income:$
Source:

TOTAL MONTHLY INCOME FROM ALL FINANCIAL SOURCES
$

AGREEMENT

MY (OUR) AGREEMENT WITH GENESEE HOME:

I (we) have read and understand the Genesee Home Scholarship Application Guidelines. I (we) am (are) willing to accept financial aid as a gift and understand that repayment is not necessary nor expected.

I (we) understand that the Genesee Home Scholarship Committee will review our application but does not make any representations or warranties with respect to the results of their financial assistance.

I (we) further agree to indemnify and hold harmless all staff and/or volunteers of Genesee Home, and its employees, agents, counselors, consultants, officers, and directors from any claim, suit, action, demand, or liability of any kind and any nature arising out of or in any manner connected with my (our) participation in these services.

I (we) hereby certify that the answers and other information on this application are true and correct and that I (we) understand any misrepresentation or omission of facts on my (our) part will disqualify me (us) from any scholarship assistance.

Pastor: * Date *

Spouse: Date

(If married, husband and wife must sign for this application to be processed)

Genesee Home
7202 Genesee Road, Taylorsville, California 95983
(530) 284-1082 Fax (530) 284-1083