Scholarship Application

Please Print Teacher Form

Note to Parents:

Please complete the following information section before giving the form to your child's teacher.

Name of Course Desired:_________________________________________________

Student's Name:_________________________________________________________

Address:_________________________________________________________________

School:__________________________________________________________________

The following part of this application should be completed by an educator who knows the above child.

Please explain why you believe this child would benefit from attending the Minds On Science Enrichment Program.

Name of person completing this form______________________________________

Position/Affiliation_____________________________________________________

Signature___________________________________ Date:____________________

Phone Number_______________________________

Return to:
Minds On Science
15 Orchard Drive, West Redding, CT 06896
(203)938-5678

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