Niagara Children’s Foundation

Gerry and Rose Frainier Scholarship

Section A: Personal Information

Name Click here to enter text.	Social Security # Click here to enter text.

Address Click here to enter text.	City/State/ZIP Click here to enter text.

Email Click here to enter text.	Phone Click here to enter text.

Section B: Professional Information

Date you began working for Empower (mm/yy) Click here to enter text.

Have you worked at least 3,600 hours (equivalent of two years) with Empower? ☐ Yes ☐ No

Current Job Title Click here to enter text.	Current Job Site/Program Click here to enter text.

Career Goal(s) Click here to enter text.

Previous Positions Held at Empower, if any Click here to enter text.

Section C: Type of Request

☐ College Tuition Assistance	please proceed to Section D

OR

☐ Professional Development Assistance (workshop, seminar or conference)	please proceed to Section E

Section D: College Tuition Assistance Request

Year of High School Graduation or GED Click here to enter text.

Past College(s) Attended Click here to enter text.

Current College/University (where this scholarship will be used) Click here to enter text.

Major/Program in Which You Are Enrolled Click here to enter text.	Credit Hours Completed Click here to enter text.

What is the time frame for which you are requesting funds? Click here to enter text.

What course(s) do you plan to take during this time frame? Click here to enter text.

How many credit hours do you plan to take during this time frame? Click here to enter text.

How much financial assistance are you requesting from Niagara Children’s Foundation? Click here to enter text.

What other sources of funding are you currently receiving? (Please check all that apply and include amounts)

☐ TAP Click here to enter text.	☐ PELL grant Click here to enter text.	☐ Loans Click here to enter text.

☐ Other scholarships Click here to enter text.

☐ Other sources (please describe and list amounts) Click here to enter text.

Please proceed to Section F

Section E: Professional Development Assistance Request

Name of Conference/Seminar/Workshop Click here to enter text.

Date(s) and Location(s) of Conference/Seminar/Workshop Click here to enter text.

Briefly describe the professional development opportunity you would like to attend, and how it will help you in your position at Empower. Please attach any brochures or other information. Click here to enter text.

Click here to enter text.

Click here to enter text.

How much financial assistance are you requesting from Niagara Children’s Foundation? Click here to enter text.

What expenses will this scholarship pay for (e.g., registration, travel, etc.)? Click here to enter text.

Section F: Signatures

Applicant Signature Click here to enter text.	Date Click here to enter text.

Division Leader Recommendation?	Yes	No	Signature ___________________________ Date_______________

Board Approval?	Yes	No	Signature ___________________________ Date_______________