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Asha Chennai

Scholarship application form for the Academic Year 2013 - 2014


Please return completed form to:
ASHA for education

85/2 First Floor, Luz Avenue


Mylapore, Chennai-600004
Mobile: 9841091424

I.

Nominator Information*

Recommended By Volunteer

Name: ________________________

Name:
Contact No:

_________________________
_________________________

Phone: ________________________
E-mail: ________________________
Address:
____________________________________________
____________________________________________

II.

Student Information
Name ___________________________________________
Date of Birth: ________________

Paste Childs Photograph


here

Gender: Male/Female

Parents/Guardians Name: (Please fill names as applicable)


Father ___________________

Mother ___________________________

Address: ______________________________________________________
Contact No*:
Relationship with Nominator: __________________________________________________
Name and address of School: __________________________________________________

Class in which the student will be in this Academic Year: (2013-2014)_______________


(Report card/Mark list/School result sheet- photocopy of the previous year to be attached)
_______________________________________________________________________

Taking any additional tuition outside of school? Please provide details: ______________
_____________________________________________________________________
1

Has ASHA Chennai scholarship been previously applied for by yourself or a family member?
Yes/ No. If yes provide details: _________________________________________________
Please provide details of any outstanding achievements in the past:_____________________
__________________________________________________________________________
____________________________________________________________________
Please provide details of any community service activities participated in the past:
____________________________________________________________________
What kind of service activity would you like to participate in? (Please answer if you are in
Class VIII upwards):
___________________________________________________________________________
___________________________________________________________________________

III

Students Family Background Information:


Reason for requesting Scholarship: ________________________________________________________
Fathers name:
Education:
Occupation:
Income*:

__________________
__________________
__________________
__________________

Mothers name:
Education:
Occupation:
Income*:

__________________
__________________
__________________
__________________

Total family income*: _________________


Information about siblings:
1. brother/sister
Education _________________
Occupation _______________
Income_______________
2. brother/sister

Education _________________
Occupation _______________
Income_______________

Does the family own


Land
own house/rented house

IV

Estimated scholarship amount needed:


(Please provide breakup details)
a.
b.
c.
d.

College/School fees:
Books and Notebooks:
Uniforms including shoes:
Any other requirements

Total:

_________________
_________________
_________________
_________________

_____________
2

Time needed to return the interest free loan to Asha (applicable for only college students.
Signing a bond is required for the amount if selected as a scholar)
_________________________

Declaration and signature by parent or guardian:

V.

I will help my child to study well at home and learn joyfully


I will use positive encouragement and avoid physical or emotional violence to discipline my
child and take the responsibility of returning the interest free loan to ASHA
Signature: ________________________________

Declaration and signature by student:

VI

I will be a responsible student and study well. I will make my parents and teachers proud. As
I am now a part of the Asha family, I understand that I must be a role model to other students.
Signature: ______________________________________

Request the nominator to provide feedback on the following:

the students progress


if any mentoring required
special support you feel the student requires in the form of tuition
Any other matter (please include details of the family circumstances and how you
know the student/family of the student)

VII.

Declaration and signature by Nominator:


I declare that the above information given by me is true. I shall monitor the students
progress (economic and academic) and report with the students mark list at the end of each
academic term. I shall ensure that the student adheres to Ashas policies and guidelines.
Signature: _______________________

Please provide the following*:

Passport size Photo


Latest mark sheet
Promotion card
Bonafide certificate
Address proof (Ration card/any ID card)
Income certificate (where applicable)
Bring the original bills (note book, book, uniforms, etc)

Please do not fill to be filled by ASHA volunteer:


Approved / Rejected

: ..

Amount approved

: ..

Comments

: ..

Signature and date :

*Mandatory