IMPACT Personal Safety
M ARI SS A’ S
S C HO LAR H SH I P
F UN D
SCHOLARSHIP APPLICATION
Please complete this application (information provided is kept anonymous) and send to IMPACT:
Email: ips@impactpersonalsafety.org
Mail: IPS, PO Box 8350, Santa Fe, NM 87504
FAX: (505) 992-8833
First & Last Name (of person completing this form): _________________________________________________________
Name of student, if different from above: ____________________________________________________________
Student’s Date of Birth: _____/_____/_____
Current Age: _____
Gender: ________________________
Street Address: _____________________________________________________________________________________
City: ___________________________________________ State: ______ Zip Code: _________________
Cell Phone: (______)___________________________ Alt. Phone: (______)_______________________
Email Address: __________________________________________________________________________
Best way to contact you (circle one):
cell phone
alt. phone
email
Take as much space as you need to complete the following questions.
1. How did you hear about IMPACT?
2. Why do you want to take an IMPACT course/your child to take an IMPACT course? (include any
information you might feel is important such as life situation, history of assault or abuse, current
dangers/fears or referred by therapist or victim advocate, etc.)
3. Why you need a scholarship?
PO Box 8350 • Santa Fe, NM 87504-8350 • 505/992-8833 • IPS@IMPACTPersonalSafety.org • www.IMPACTPersonalSafety.org
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IMPACT Personal Safety
4. What are your current sources of income (if any)?
5. Are you willing to write a testimonial about your/your child’s experience in the course to share with
potential funders and donors when we ask them for donations to our scholarship fund?
-------------------------------------------------------------All Scholarship Recipients are required to pay a co-pay to reserve their space in a class. There are a
limited number of scholarship spots per class and your non-refundable co-pay shows your commitment to
the course. You may arrange for an interest-free payment plan over several months. The co-pay is a range;
you pay what you can afford as follows:
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Adult Basics (reg. $450) Scholarship Sliding Co-Pay Range: $50-$300
Teen Basics (reg. $225 -automatic scholarship-) Scholarship Sliding Co-Pay Range: $50-$200
Intro Workshop (reg. $75, seniors $50) Scholarship Sliding Co-Pay Range: $20-$50
Children’s Workshop (reg. $125) Scholarship Sliding Co-Pay Range: $25-$100
In which course, in which month, do you wish to enroll? What copay are you applying for?
List course name and month it takes place and the amount of copay you are able to pay for the course.
Example: Women’s Basics, April 2013, $200 copay
Any additional information you want to provide:
Upon submission of the application you are verifying that the information you have given
on this application is complete and true.
It can take 1-3 weeks to review your application. Upon approval, you will be contacted.
PO Box 8350 • Santa Fe, NM 87504-8350 • 505/992-8833 • IPS@IMPACTPersonalSafety.org • www.IMPACTPersonalSafety.org
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