Tuition Assistance Application

Students Name *

First

Last

Birthday

Address

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Checkboxes

Home Phone
Cell Phone

Phone

Student info

If Applicable: School & Grade

Total Cost of Tuition$

Current combined annual household income: $ *

Parent/Guardian Info

Parent/Guardian # 1 *

First

Last

Parent/Guardian # 1 - Address

Address Line 1

Address Line 2

City

State

Zip Code

Guardian #1 - Phone

Parent/Guardian # 1 - Email *

Parent/Guardian # 1 - Employer/Position

Parent/Guardian # 1 - Employer/Position (copy)

Parent/Guardian # 1 - Employer Phone

Parent/Guardian # 1 - Gross Annual Income

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

YES, this is ok for my signature
NO, this is not ok for my signature

Parent/Guardian # 2 *

First

Last

Address (Parent/Guardian # 2)

Address Line 1

Address Line 2

City

State

Zip Code

Guardian #1 - Phone (Parent/Guardian # 2)

Email (Parent/Guardian # 2) *

Employer Phone (Parent/Guardian # 2)

Employer (Parent/Guardian # 2)

Gross Annual Income (Parent/Guardian # 2)

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.
If selecting "NO", this is not ok for my signature, you will need to visit Berkshire Pulse and sign a form for us.

Please explain why you are applying for tuition assistance:

Please provide any additional information you think we should consider: