R.E.A.D. Scholarship

Section 1: Applicant Information

Applicant’s full legal name *

Preferred name

Date of birth *

Age *

Gender (optional)

Home address *

City, state/province, postal code, and country *

Applicant’s phone number (if applicable)

Applicant’s email address (if applicable)

What is the applicant’s current level of education? *

Section 2: Parent or Guardian Information

Complete this section if the applicant is under 18 or requires support completing the application.

Parent or guardian’s full name

Relationship to the applicant

Parent or guardian’s phone number

Parent or guardian’s email address

Parent or guardian’s home address (if different)

Who should Quality Smile Restorers Inc. contact regarding this application? *

Section 3: School Information

Name of the school, college, university, or training institution *

School address and country *

Current grade, class, year, or academic level *

Expected graduation or completion date *

Name and contact information of a teacher, school administrator, academic adviser, or counselor *

Is the applicant currently enrolled? *

Please briefly describe the applicant’s academic performance and progress. *

What subjects, courses, or areas of study does the applicant enjoy most? *

Has the applicant received any academic awards, certificates, honors, or recognition? Please explain. *

Section 4: Scholarship Request

What type of educational support are you requesting? *

What is the total amount being requested? *

Please provide a breakdown of how the scholarship funds would be used. *

When are the funds needed? *

To whom should approved funds be paid? *

Has the applicant received a R.E.A.D Scholarship before? *

Has the applicant applied for or received financial assistance from another organization? Please explain. *

Section 5: Financial Need

Please describe the applicant’s current financial need. *

What circumstances have made it difficult for the applicant or family to meet educational expenses? *

How many people live in the applicant’s household? *

How many school-aged children or dependents are supported by the household? *

What are the main sources of household income? *

Are there any special family, health, disability, housing, employment, or caregiving circumstances that should be considered? (Optional)

What educational expenses can the family currently contribute toward? *

What may happen to the applicant’s education if scholarship support is not received? *

Section 6: Applicant’s Goals and Personal Statement

For younger applicants, a parent, guardian, teacher, or support person may help record the applicant’s answers.

Why is education important to you? *

What are your educational and career goals? *

What challenges have you experienced while pursuing your education? *

How have you worked to overcome those challenges? *

How would the R.E.A.D Scholarship help you continue or improve your education? *

What personal strengths, talents, or qualities are you most proud of? *

How do you support or positively contribute to your family, school, or community? *

What does the phrase “More Smiles, Less Stress” mean to you? *

In 150–300 words, describe why you believe you should be considered for the R.E.A.D Scholarship. *

Section 7: Community Involvement

Does the applicant participate in any community, school, volunteer, faith-based, cultural, leadership, sports, arts, or recreational activities? Please describe. *

Has the applicant helped another person or contributed positively to the community? Please provide an example. *

How does the applicant plan to use their education to support others in the future? *

Section 8: Supporting Documents

Please upload relevant documents (PDF, JPG, PNG)

Proof of school enrollment, report cards, fee statements, letter of recommendation, proof of identity, etc.

If any required document is unavailable, please explain why.

Section 9: Reference or Recommendation

Reference’s full name *

Reference’s title or relationship to the applicant *

Reference’s organization or school *

Reference’s phone number and email address *

How long has the reference known the applicant? *

Why does the reference believe the applicant should receive this scholarship? *

Section 10: Applicant Agreement

I confirm that the information provided in this application is accurate and complete. * Yes No

I understand that submitting an application does not guarantee that a scholarship will be awarded. * Yes No

I authorize Quality Smile Restorers Inc. to contact the school, reference, parent, guardian, or listed service provider to verify information related to this application. * Yes No

I understand that scholarship funds may be paid directly to the school, educational institution, or approved provider. * Yes No

If selected, I agree to provide reasonable updates regarding enrollment, attendance, educational progress, and the use of scholarship support. * Yes No

May Quality Smile Restorers Inc. use the applicant’s first name, general educational story, or scholarship outcome in reports and fundraising materials? * Yes No Please contact me first

May photographs or videos of the applicant be used for approved Quality Smile Restorers Inc. communications? * Yes No Please contact me first

Applicant’s signature (Type full name) *

Parent or guardian’s signature, when applicable (Type full name)

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