A Registered 501(c)3 Public Charity

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)

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