David H. Clark Memorial Fund Application Form

Please mail to: STRIDE, Inc.   PO Box 778, Rensselaer, NY 12144.

Please PRINT.                                                 Date of Application: ___________________

Current STRIDE Application on file?   ___Yes       ___No

Name of Applicant________________________________________________________

Address_________________________________________________________________

_______________________________________________________________________

Phone number (      )__________________            Date of Birth_____________________

Name of parent or guardian_________________________________________________

Address and phone number (if different from above)_____________________________

______________________________________________________________________    

E-Mail Address __________________________________________________________

For what is the child requesting an award?______________________________

What is the cost? (if known)_____________________________________

Name of school child attends________________________________________________

Family/Guardian income level:  (please check one)

Below $20,000 ____     $20,000-$40,000____  $40,001-$60,000___   

$60,001-$80,000___     $80,001-$100,000___   Above $100,000___

Number of Dependents Living at Home ________________

Additional Financial Information and References may be required.

Please describe why this child is deserving of a financial award from STRIDE?

(please use back of form or attach additional sheets, if needed)  ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Name (print):  ____________________________

Signature:       ____________________________

Date:               ____________________________