Scholarship Form

Income

Income

Scholarship Agreement

I understand that failure to attend the program on a regular basis and/or failure to make your payments, when so applicable, shall result in loss of scholarship and/or dismissal from Latchkey. My scholarship may be revoked due to inconsistent attendance, abuse or services, or loss of funding. These funds may no longer become available and could result in the scholarship being discontinued without notice.

Certification

I certify that the information provided to Latchkey Child Services Inc on my scholarship application is true and correct to the best of my knowledge and belief.

PENALTY FOR FALSE OR FRAUDULENT STATEMENT: U.S.C. Title 18, Sec. 1001, provides: “Whoever, in any matter within the jurisdiction of any department or agency of the United States knowingly and willfully falsifies … or makes any false, fictitious, or fraudulent statement or entry, shall be fined not more than $10,000 or imprisoned not more than five years, or both.”