White Plains Presbyterian Church Nursery School (WPPCNS)
                                                                                  Scholarship Application
Name of Child: _____________________________________        Male         Female
Date of Birth: __________________________________
Mother’s name:__________________________________
Address: _________________________________________________________
Phone Number: _________________________________
Father’s name: __________________________________
Address: _________________________________________________________
Phone Number: _________________________________
With whom does the child live? (please circle one)
Mother         Father          Both parents                     Other (name and relationship) ______________________
Other children living in the home                Age/Relationship                      WPPCNS Alumni?
Is there someone in the community who knows you and/or our child that we may contact to get to know you
and/or your situation better?
Name/Relationship: __________________________ Phone: _________________________
How did you learn about the scholarship program?

Do you qualify for any public assistance program? (Circle all that apply)    No           Yes (food stamps, unemployment, supplemental housing)    
   If yes please provide the benefit number: _______________________

Financial Information
This information is used solely to determine scholarship eligibility and will remain confidential.
Father’s Information:
Place of employment___________________________________________________
How long have you worked there? ___________ Work phone number ___________________
Mother’s Information:
Place of employment________________________________________________________
How long have you worked there? ___________ Work phone number ________________
Are other adults contributing to the household income? ___________
If yes, please explain. _____________________________________________________
Please supply the following information, as well as a copy of PAGE 1 of your most recent Federal Income
Tax Form (applications will not be considered complete without ALL requested information). Please indicate
if an item is not applicable (N/A).
Monthly: (Gross) $______________ (Net) $_____________
Annually: (Gross) $ ______________ (Net) $_____________
Expenses (per month):
Mortgage   or     Rent (Circle one): $_____________ Groceries: $______________
TV/Cable: $_______________ Phone (home) $______________ Phone (cell) $_____________
Home Gas/Electric $______________ Insurance: $_______________
Auto:                                                             Medical:
Insurance (yearly): $______________        Insurance Premiums (yearly): $____________
Payments $__________________               Other: $_______________
Gas/month: $______________________         Other:_____________________
Other Insurance: _____________          Credit Card debts $: _________________
Other Loans/Debt: ___________________________________________________________

Please describe any special financial circumstances affecting the family’s budget.
Please add any additional information that you think will be helpful in better understanding your financial situation.
Each application will be reviewed considering both financial information as well as extenuating circumstances. If
additional space is needed, please attach pages to this application.
Return to the WPPC Nursery School Director:
● This Scholarship Application (along with any additional information)
● A copy of your 2 most recent Income Tax Forms*
● A copy of White Plains Presbyterian Church Nursery School application or registration contract
● A SIGNED copy of the Financial Obligation Acknowledgment form
I verify that the above information is true and complete.
Signed: _____________________________________ Date: _________________
Signed: _____________________________________ Date: _________________
Please return all completed forms as soon as possible in person or mail to:
White Plains Presbyterian Church Nursery School, Attn School Director,
39 North Broadway, White Plains, NY, 10603
*If you have filed for an extension or do not file income taxes, please provide copies of all
applicable W2’s from the most recent 2 years along with any other income documentation (child support,
alimony, unemployment etc).

Financial Obligation Acknowledgement Form:
(Please initial on the lines)
_________I/we understand that if our child is awarded scholarship money through the White Plains Presbyterian Church Nursery School Scholarship Program that it is our sole responsibility to make timely tuition payments to the school. We will not be provided reminders that payment is due.

_________Unless alternate arrangements are made; payments are due the 1st of the month, with
late fees incurred after nonpayment by the 10th of the month (as per the handbook).
Failure to make a monthly payment by the 20th of the month will: preclude your child (ren) from attending school until payment (along with any applicable late fees) is made to the School and may result in the withdrawal of your scholarship whereas the remaining balance will be your responsibility.

_________The teachers will be asked to assess the attendance of ALL students in February.
I/We understand that if our child has had an unreasonable (nonmedical) number of absences, we may be required to refund the school the scholarship money awarded to us.

_________I/we understand that it is OUR responsibility to communicate any delays in payment to the School Director. I/we also understand that payment plans are available through the
Registrar should we need to spread our payments out over a longer period.
Parent/Guardian Signature Date
Parent/Guardian Signature Date