Scholarship : About Us : Terre Haute Boys & Girls Club

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Child's Name

First Name *

Last Name *

Child’s Address

Country

Address Line 1 *

Address Line 2

City *

State/Province *

Postal Code *

Child’s Age (Required)

Mother’s Name

First Name *

Last Name *

Mother’s Occupation (Required)

Father’s Name

First Name *

Last Name *

Father’s Occupation (Required)

Child Lives With (Required)

Total single household size (Required)

Siblings (please list name, age and member Y/N) (Required)

Total monthly family income (include child support) (Required)

Assistance

Child Support

Contact Phone Number (Required)

Is this child a current member?

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