CHARLES R. DREW WELLNESS CENTER

SCHOLARSHIP APPLICATION

Scholarship mission:

To provide recipients with the environment and tools needed to prevent, improve and/or maintain a healthy lifestyle through education, recreation, fitness and health programs.

Purpose of scholarship:

To provide financial assistance to applicants who are financially unable to purchase Drew memberships. Scholarships are provided on a fair and open basis without regard to race, religion, color, sex, age national origin, marital status or any other classification protected by applicable local, state or federal law.

Eligibility:

A scholarship application must be completed and submitted, and applicant must provide the following information:

Proof of Income (Please provide one):

·  Most current pay stubs or unemployment benefits (1 month)

·  Federal and state agency award letter, i.e. AFDC, Social Security,

SSI award letter

Proof of Residency (Please provide one):

·  Most current SC Driver’s license

·  Most current utility bill (water or electricity)

·  Current lease or mortgage agreement

Personal letter explaining why you would like to be considered for a scholarship

Scholarship guidelines:

1.  Scholarships are awarded four times a year (quarterly) and are good

for three months.

2.  Scholarship recipients must sign a waiver of liability.

3.  Scholarship recipients must attend orientation as well as complete health screenings/physical evaluations prior to using the wellness center.

4.  Scholarship recipients must attend the wellness center at least three times a week (attendance will be monitored weekly).

5.  Scholarship recipients that are not attending the wellness center at least three times a week as agreed may lose their scholarships. Cancelled awardee will be notified in writing.

6.  Repeat applications will be reviewed by the committee and will be subject to the availability of funds.

Application for Charles R. Drew Wellness Center Scholarship

Name: ______

Address: ______(City, State & Zip) ______

Sex: Female ______Male______

Telephone no.: Home______Work ______Cell______

Birth Date: ____ // ____// ______Marital Status: ______

List all family members that will be using the scholarship:

Name Birth Date Sex Age

______//___//______

______//___//______

______//___//______

______//___//______

Income Information:

Name of Members who live in household with income / Name of
Employer / Gross Weekly Wages / Welfare / Child Support Monthly / Social Security Benefits / Unemployment Benefits / All other income
1. / $ / $ / $ / $ / $ / $
2. / $ / $ / $ / $ / $ / $
3. / $ / $ / $ / $ / $ / $

Type of scholarship requested: Individual: Youth_____ Family______

(Please check one) Adult _____ (nuclear family)

Senior_____ (max of 4 family member)

Applicant Signature______Date:______

By signing this document, I acknowledge that; the scholarship program is a voluntary activity; that I agree to follow the rules and regulations of the scholarship program; that non-compliance with the regulations could result in termination of the scholarship; that any private and medical information collected through this process will be used solely for evaluating my acceptance into the program as well as the effectiveness of the program.

Please submit an original application to:

Charles R. Drew Wellness Center Scholarship Committee

2101 Walker Solomon Way

Columbia, South Carolina 29204