Youth Cycling Scholarship Application

Parent/Guardian Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Child's Name *

First Name

Last Name

How many people are in your household?

*This information is for aggregate reporting purposes only. Your information remains confidential.

2

3

4

5

More than 5

What is your total family income? *

*This information is for aggregate reporting purposes only. Your information remains confidential.

Less than $30,000

Between $30,000–$45,000

Between $45,000–$60,000

Between $60,000–$75,000

Over $75,000

Which race or ethnicity best describes you? (Please choose only one.) *

*This information is for aggregate reporting purposes only. Your information remains confidential.

American Indian or Alaskan Native

Black or African American

White or Caucasian

Hispanic or Latino

Prefer not to answer