Movie & a Cuddle Scholarship Application - December 8th

Applications must be submitted by December 5th, 2023. Our programs sell out very quickly and we recommend that you return the scholarship application as soon as possible. Spaces are limited and will be filled on a first-come, first-served basis. All scholarships for this program will cover 100% of the fee.

Please contact afaulk@hssaz.org (520.327.6088 ext 171) with any questions. To submit any supplemental information, please email it to the above listed email, mail to 635 W Roger Rd, Tucson AZ 85705, OR fax to 520.325.7190.

Please be aware that the Humane Society of Southern Arizona will only grant one scholarship per household.

Question Title

* 1. Please provide the following information

Child's First and Last Name *

DOB *

Parent/Legal Guardian's Name *

Mailing Address *

City/Town *

State/Province *

ZIP/Postal Code *

Home Phone

Cell Phone *

Email *

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* 2. Please check all that apply:

As the parent or legal guardian, I am currently receiving financial assistance from the government (AHCCCS/Food Stamp Program). Please submit a legible copy of your AHCCCS or Food Stamp Card.

The child is receiving services through one of Arizona's Behavioral Health Systems. Please contact the child's case worker to submit a letter, on official letterhead, to us stating that they believe this program would be beneficial for the child. Please be aware that the program you are applying for may not be psycho-educational in nature.

The child is currently in state care or custody. Please contact the child's case worker to send us a letter, on official letterhead, confirming the child is in state care/custody.

If you and your family do not qualify for one of the above circumstances, please briefly explain below why this child will benefit from this program or why you are applying for a scholarship.

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* 3. Please submit any supplemental documentation for the question above. These documents can also be sent to the contact information above, but MUST be submitted by December 5th, 2023 or the application will not be considered.

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* 4. Please give us a brief description of your scholarship need.

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* 5. Please review and acknowledge the following statements:

I understand the completion of this application does not guarantee funding for my child. I further realize that the Humane Society of Southern Arizona has limited funding available and that I may be denied funding support. This application will remain confidential and will be kept by the Humane Society even if I do not receive funding support.

I understand that if my child is granted a scholarship and I don't respond by the requested date, I may be ineligible to receive another scholarship from the Humane Society of Southern Arizona for one year.