Student Name *

First Name

Last Name

Phone *

(###)

###

####

Sponsor's Name *

First Name

Last Name

Phone

(###)

###

####

OUR KAY CLUB IS REQUESTING A MATCHING SCHOLARSHIP FROM KAYAN. *

We are requesting funds for a partial scholarship.

We are requesting funds for a member who has never attended KLC.

We are requesting the following scholarship:

$50

$75

$100

$125

$150

$167.50 (half of the camp fee)

Sponsor Acknowledgement and Signature *

I understand that if the student is awarded a KLC scholarship, the student must attend KLC this summer. Failure to attend KLC this summer will result in our club reimbursing the awarded amount to KAYAN.

Yes, I agree.

No, I do not agree.

Student Acknowledgement and Signature *

I understand that if I receive a KLC Scholarship, I must attend KLC this summer. Additionally, I must be an active KAY member in upcoming school year. I understand that should I not attend KLC this summer, I may be responsible for reimbursing KAYAN in the amount of my awarded scholarship.

Yes, I agree.

No, I do not agree.