The Application

Parent/Guardian Name *

First Name

Last Name

Parent/Guardian Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian Phone *

(###)

###

####

Which of the following best describes you? Select all that apply. *

This is for data collection purposes only. Bloom Academy admits children of any race, color, religion, gender, disability, sexual orientation, or national and ethnic origin to all the rights, privileges, programs, and activities generally accorded or made available to children at the center. This public benefit organization does not discriminate on the basis of race, color, religion, gender, disability, sexual orientation, or national and ethnic origin in administration of its educational policies, admissions policies, scholarship and financial aid programs, employment policies, or election of officers or membership.

American Indian or Alaska Native

Asian

Black or African American

Hispanic, Latino, or Spanish Origin

Middle Eastern or North African

Native Hawaiian or Other Pacific Islander

White

Other

Prefer not to disclose

Child's Name *

First Name

Last Name

Second Child's Name (if applicable)

First Name

Last Name

Scholarship Requirements *

The availability of funds is dependent upon recurring and one time community donations. To leverage continued support for Bloom Academy, recipients of the Bloom Academy Scholarship are required to provide in-kind services and support for Bloom by hosting a minimum of one (1) Parents’ Night Out. Parents’ Night Outs are roughly 3-hour-long events that happen outside standard Bloom hours. The purpose of the event is to provide both Bloom and non-Bloom children with a themed-evening that includes an activity or project of the host’s choice. Depending upon the extent of scholarship provided, additional in-kind donations of time and/or resources support will be determined between families receiving assistance and Bloom staff.

I understand that if selected as a Scholarship recipient, I will be required to host a minimum of one (1) Parents' Night Out during the session of which I am receiving the funds.

I understand that 100% of the money raised from the Parents' Night Out will go back into the Scholarship Fund for future use.

I understand that, depending on the amount received from the Scholarship fund and the amount raised from my hosted Parents' Night Out, I may be required to contribute further either through addition fundraisers, volunteering, etc.