KURT KELLY HOCKEY MEMORIAL FUND SCHOLARSHIP Parent(s)/Guardian(s) Name(s) Address City/State/Zip Home Phone Work Phone Cell Phone Email Address Player's Name Player's Date of Birth Years playing hockey Number of siblings playing in the CHA Level of play (select one) MiteSquirtPee WeeBantamMidget School attending 2014-15 Grade Gross Household Income 2013 (Applicants must be willing to provide a tax return summary page upon request) To be completed by child with help from parent/guardian Why do you like to play hockey? What qualities has hockey helped you develop? By typing my name below, I acknowledge that all the above information is true and complete. I also agree to provide the supporting financial documentation as requested, and agree to update the scholarship fund if my financial status changes after submission of this application. Parent/Guardian Signature Date Player Signature Date
