2015 Financial Aid Request Form
INSTRUCTIONS
Tuition for the 2015 Emerge program is $650. Leadership Austin donors have established some sources of financial aid for Emerge participants. This
aid varies in terms of quantity and dollar amount. Financial aid requests are considered only after the Emerge class selection process is complete and
will in no way impact consideration of your application. To submit a financial aid request, please complete this form and submit it as an attachment
with your Emerge application. Please note: to assure that limited financial aid funds are equitably distributed, requests must be submitted with the
initial application by 5:00 pm on Monday, June 29. Incomplete or late requests will not be considered.
As financial aid funds are limited, applicants are asked to consider requesting funds only as a last resort, after taking advantage of
available contributions from employers and community organizations for which they have served.
PERSONAL INFORMATION
Name
Phone
Email
TUITION ASSISTANCE REQUEST
I will personally commit funds toward my Emerge tuition in the amount of:
I would like to discuss setting up a payment plan (not to extend past December 2015) for this amount.
My employer will commit funds toward my Emerge tuition in the amount of:
I will raise funds toward my Emerge tuition from other sources in the amount of:
I am requesting a scholarship for tuition in the amount of:
Total Class tuition
$650
EXPLANATION OF REQUEST (REQUIRED)
Please write a brief explanation of why you are requesting this financial aid:
COMMITMENT STATEMENT AND SIGNATURE
I vow that I have exhausted all options to locate funding for Leadership Austin Emerge Class tuition, and respectfully ask for tuition assistance in the
amount above for the 2015 Emerge Class. In exchange, knowing that Leadership Austin has limited scholarship funds, I offer to repay this
opportunity by dedicating my time and talent to the community as a civic leader. In addition, I will support the efforts of Leadership Austin and
pledge to donate my services as an active volunteer and/or alumni.
I understand that, should I be selected into the Emerge Class, my request will be reviewed and I will be asked to negotiate terms of an agreement
with Leadership Austin. The completed section below will serve as my electronic signature.
Applicant Full Name
Date
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Last 4 Digits of SSN
LEADERSHIP AUSTIN STAFF TO COMPLETE
Confirmed Application Category
Yes
No
Yes
No
Tuition Amount Awarded
Applicant Notified
Completed By
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