Tuition Assistance Application Please enable JavaScript in your browser to complete this form.Name *FirstLastBirthdayAddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmail *PhoneHome PhoneCell PhonePhone *Student InfoIf Applicable: School & GradeTotal Cost of Tuition$Current combined annual household income: $ *Parent/Guardian InfoParent/Guardian # 1 *FirstLastParent/Guardian # 1 AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeParent/Guardian # 1 EmailParent/Guardian # 1 – Employer/PositionParent/Guardian # 1 Phone *Parent/Guardian # 1 – Gross Annual IncomeThis 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 NameFirstLastParent/Guardian # 2 AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeParent/Guardian # 2 PhoneParent/Guardian # 2 EmailThis 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. ChoicePlease 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.Starting as of December 11, 2023, for new Tuition Assistance applicants, those with a valid ConnectorCare card will automatically be guaranteed at least 50% Tuition Assistance and up to 100% Tuition Assistance, based on need. To qualify, please submit a copy of your ConnectorCare card. By checking this box, I am agreeing to provide proof of my ConnectorCare card, either by emailing Susan Ingersoll at susan@berkshirepulse.org, or by bringing it in to Berkshire Pulse.Submit