Tuition Assistance Application

Regular Tuition Assistance Application

Please fill out the form below to apply for Tuition Assistance. As a reminder, this is our REGULAR Tuition Assistance application. If you have a valid EBT/WIC card, please fill out this one-page application along with proof of your card. If you are unable to provide a current Form 1040, please use this alternative TA application form.

Name *

First

Last

Birthday *

Email *

Address *

Phone *

Phone

Home Phone
Cell Phone

If Applicable: School & Grade

Total Cost of Tuition$

Current combined annual household income: $ *

Parent/Guardian # 1 *

First

Last

Parent/Guardian # 1 Address

Parent/Guardian #1 Phone

Parent/Guardian # 1 Email

Parent/Guardian # 1 – Employer/Position

Parent/Guardian # 1 – Gross Annual Income

This is approving this as my electronic Signature. (Parent/Guardian #1)

By selecting ‘YES’, I agree that all the information provided is accurate and I consent to Berkshire Pulse’s policies.
If selecting “NO”, this is not ok for my signature, you will need to visit Berkshire Pulse and sign a form for us.

Parent/Guardian # 2 Name

First

Last

Parent/Guardian # 2 Address

Parent/Guardian #2 Phone

Parent/Guardian # 2 Email

This is approving this as my electronic Signature. (Parent/Guardian #2)

By selecting ‘YES’, I agree that all the information provided is accurate and I consent to Berkshire Pulse’s policies.
SecondIf selecting “NO”, this is not ok for my signature, you will need to visit Berkshire Pulse and sign a form for us. Choice

Please explain why you are applying for tuition assistance:

Please provide any additional information you think we should consider:

To complete the application:

Tuition Assistance applicants must include most recent IRS Form 1040 with all attached schedules and business IRS schedule C. Both parents must submit a 1040 if filed separately. Include all sources of income, including but not limited to salary, tips, bonuses, maintenance, and child support. By checking this box, I am agreeing to provide this information, either by emailing Susan Ingersoll at susan@berkshirepulse.org, or by bringing paper copies to Berkshire Pulse.
If your family has an EBT or WIC card from another state other than Massachusetts, please fill out this regular Tuition Assistance application and provide proof of your card – 100% Tuition Assistance is not guaranteed for applicants outside of MA, but, your card verification will be in lieu of sending the above additional financial information.

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Regular Tuition Assistance Application