Educational Assistance Application
Margarett Keller Scholarship

First Name

Email
Address

Last Name
Phone
City
State
Zip Code
Educational Needs

School you plan to attend or are attending

Major

Registration Date
Number of years you plan to attend

Contact Name
Phone
Are you receiving financial aid? (Loans, Grants, Other)

Needs to be considered (books, gas, childcare, tuition)

Family members living in your household (names and ages)

Education and Years Attended/Graduated(high school, etc.)

Goal of this education experience (Career, etc.)

References

Reference Name
Phone
Address

City
State
Zip Code
Monthly Fixed Expenses

Rent/Mortgage
Car Loan
Other Loans
Credit Cards
Alimony/Child Support
Utilities
Car Insurance
Totals
Monthly Variable Expenses

Clothing
Groceries
Medical
Child Care
Transportation/Gas
Auto Repair
Other
Totals
Monthly Income

Employment
Child Support
Social Security
Alimony
Work First
S.S.S.D.I
S.S.I
Other
Totals
Subsidies

Food Stamps
Housing
Medicade
Smart Start
W.I.C
Totals
Other

Are there any special financial circumstances in your family that we need to consider?
Type in todays date in this format with dashes: (YYYY-MM-DD)


Margaret Keller Scholarship


Dorcas Ministries
1231 N.E. Maynard Rd.
Cary, North Carolina 27513
(919)469-9861

I understand that the mission of Dorcas Ministries is to support families and individuals in crisis. This emergency assistance is not intended to be an income supplement or to be provided on a regular basis. By accepting the terms of this form, I give Dorcas Ministries permission to contact whomever necessary to verify my need, make a responsible decision regarding assistance to my household, and to seek further resources with regard to my request. This permission includes but is not limited to, landlords, mortgage companies, utility or other service providers, medical providers and pharmacies.

I also understand the information I provide will be used to verify my need, negotiate on my behalf, and to assist my household or other agencies assisting my household. My acceptance of this form indicated that all information I have given Dorcas Ministries is accurate and complete to the best of my knowledge.

I understand that if I have given false information my household and I will be barred from receiving any future assistance from Dorcas Ministries. Also, the incident may be shared with other organizations.

How To Apply


In order to successfully apply for assistance you must fill out the application on the left in its entirety. Once complete you may either

1)Submit the application online where it will be sent to Scholarship Committee for review

or

2)Click Create Word Document and print the application off either mail it or bring it to the Dorcas Ministries facility.