EASTERN REGION BBYO SCHOLARSHIP APPLICATION
NAME OF CONVENTION OR DUES YEAR _______________________
AMOUNT OF SCHOLARSHIP REQUESTED: ____________________ (Please specify and amount)

The information requested on this form will be kept strictly confidential.

You must be a member in good standing to apply for financial aid.

Scholarships are based on financial need. No 100% scholarships will be awarded.

Requests for over 25% of the program cost, requires the submission of the first 2 pages of the
most recent Income Tax Form-1040.Eastern Region will not consider any scholarship requests
over 25% without this form.

All requests must be received by the deadline established by the regional director. The
family will be notified as to the amount of the scholarship via email within 3 days of the
scholarship deadline.

Please submit this application and the 1040 tax forms ( if asking for over 25%) to
Eastern Region BBYO,
5007 Providence Road, Suite 106,
Charlotte, NC 28226 - Fax to 704-362-4179 or scan and email to egoldstein@bbyo.org
PART 1: Teen Information
Name: _____________________________________Date of Birth: _____________
Address: ___________________________________________________________
City: ________________________ State: _________
Phone: (
) ________________
Zip: ________________
Teen Email: ____________________________
PART 2: Parent/Guardian Information
Parent/Guardian 1:________________________________________________________
Address: ________________________________________________________________
City: _________________________ State: _________
Home: (
) _____________ Cell:(
Zip: _____________________
) _____________ Email: ____________________
Parent/Guardian 2:________________________________________________________
Address: ________________________________________________________________
City: _________________________ State: _________
Home: (
) _____________ Cell:(
Zip: _____________________
) _____________ Email: ____________________
PART 3: Teen Applicant Section
Grade: ______Years in BBYO: _______ Present BBYO Position: __________________
Past Positions: _____________________________________________________________
What activities have you been involved with in your chapter?
__________________________________________________________________
What activities have you been involved with in your Region/International?
__________________________________________________________________
List past BBYO conventions you have attended:
________________________________________________________________________________
____________________________________________________
Why do you wish to participate in this program? ____________________________
__________________________________________________________________
Please indicate approximately how much money you make each week through job, allowance, babysitting, etc.
to contribute to the cost.________________________________
PART 4: Family Income
To be completed by the applicant’s parent/guardian. To be considered for a scholarship that is greater than
25% of the of the total program cost, you must submit a copy of the first 2 pages of your most recent 1040 tax
form.
NAME
EMPLOYER
GROSS ANNUAL EARNINGS
OTHER INCOME (e.g. Rent Support, Pension, Investments, Disability, etc.)
SOURCE
ANNUAL INCOME
________________________________________________________________________________
________________________________________________________________
FAMILY EXPENSES
NUMBER OF DEPENDENTS
1. Dependent children under age 12
Dependent children ages 12-18
Dependent children ages 19-24
Other dependents
___________
___________
___________
___________
2. Annual cost for nursery or day care
Annual cost for private school (K-12)
Parent contribution for college this year
Number of children in college
___________
___________
___________
___________
Please explain any special financial circumstances and the reasons for submitting this application: