St. Thomas’s Community Preschool, Inc.

119 Caroline Street

PO Box 147

Orange, VA 22960

540-672-2337

Mission Statement

Our mission is to provide a balanced curriculum of age-appropriate scholastic and Christian education for preschool children in an enjoyable, socially nurturing environment

St. Thomas’s Community Preschool would like to offer tuition assistance to qualified students. All applicants are given equal consideration. Tuition Assistance information is kept strictly confidential. All decisions of the Tuition Assistance Committee are final.

Request for Tuition Assistance

Names of Parents/Guardians: _______________________________Date: _____________________

Occupation of Farther: _____________________________Mother: ____________________________

Number Living in Household: Adults ______ Children_______ Other siblings enrolled?_____________

Name of Child for which Scholarship is Requested: _________________________________________

Amount of Tuition you will be able to pay: ________________________________________________

Monthly Income:

Salary of Father $_______________ Child Support $_______________

Salary of Mother $_______________ Alimony $_______________

Workman’s Compensations $_______________ Other Sources of Income $_______________

Assistance (Food Stamps, Relatives, etc.) $_______________

Total Monthly Income $_______________

PLEASE ATTACH COPY OF PAY RECORD OR LAST YEAR’S INCOME TAX RETURN

Expenses:

Rent/House Payment $_______________

Utilities $_______________

Food $_______________

Clothing $_______________

Transportation/Gasoline $_______________

Medical $_______________

Tuition $_______________

Child Care $_______________

Other (Identify) $_______________

Total $_______________

I certify that the above information is correct to the best of my knowledge:

________________________________________________________

(Signature of Parent/Legal Guardian)

St. Thomas’s Community Preschool does not discriminate on the basis of race, color, or national ethnic origin of its students.

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For Office Use

Scholarship approved:___________________Not Approved____________________Effective Date:____________________

Amount of Scholarship Awarded:___________________

Director’s Signature:__________________________ Board of Director’s Signature:__________________________

Chairperson/Treasurer’s Signature:___________________________