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Scholarship Information

Applicant (Child/Student) Information

Applicant's Name *

First

Middle

Last

Applicant's Address *

Address Line 2

City

State

ZIP Code

Applicant's Phone (Home)

Applicant's Phone (Work)

Applicant's Phone (Cell)

Applicant's Email *

Enter Email

Confirm Email

Applicant's Date of Birth *

Parental/Guardian Information

First

Middle

Last

Parent/Guardian’s Address

If different from above

Street Address

Address Line 2

City

State

ZIP Code

Parent/Guardian’s Phone (Home)

Parent/Guardian’s Phone (Work)

Parent/Guardian’s Phone (Cell)

2nd Parent/Guardian’s Address

If different from above

Street Address

Address Line 2

City

State

ZIP Code

2nd Parent/Guardian’s Phone (Home)

2nd Parent/Guardian’s Phone (Work)

2nd Parent/Guardian’s Phone (Cell)

Injured/Deceased Worker Information

Name of Injured/Deceased Worker *

First

Middle

Last

Date of Birth of Injured/Deceased Worker *

Address of Injured/Deceased Worker

Street Address

Address Line 2

City

State

ZIP Code

Date of Injury *

Claim Number(s) *

Workers’ Compensation Carrier *

Name of Employer *

Employer of Record (when accident/injury/illness/death occurred)

Name of Employer *

Employer Address *

Address Line 2

City

State

ZIP Code

Applicant - School Information

Name of Current School Attended/Attends *

School's Address *

Address Line 2

City

State

ZIP Code

Name of School/Institution/Apprentice Program Applicant Plans to Attend *

School's Address*

Address Line 2

City

State

ZIP Code

Have you already been accepted by this institution? *

Yes

Date you will be starting/continuing education at this institution is: *

Major Field of Study *

Career objectives *

Tuition Information *

Have you been awarded any other scholarship or financial aid? *

Yes

If yes, please identify the entity that has awarded the scholarship/financial aid and specify the amount awarded.

Entity Name

Amount Awarded

Entity Name

Amount Awarded

Entity Name

Amount Awarded

If yes, please identify the entity that has awarded the scholarship/financial aid and specify the amount awarded.

Entity Name

Amount Awarded

Entity Name

Amount Awarded

Entity Name

Amount Awarded

Documentation

You may upload the required documents now or send separately to Kids Chance of Oregon after your online application has been submitted

Documentation Required:

A completed Kids’ Chance of Oregon Scholarship Application
Transcript of most recent grades
Student Account Statement from the university, college, technical school, apprentice program or high school Applicant plans to attend
Documentation of compensability that the injury or death of the parent or guardian was determined to be an Oregon covered injury or death.
Essay/Statement Regarding Needs and Goals (limited to two pages)
Letter(s) of Recommendation

Please note: Applications are only considered submitted when all required documentation has been received by Kids’ Chance of Oregon, Inc.

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