2017 SCH OLARSH IP PROGRAM

An i n vestm en t i n chan gi n g l i ves. The FUSION SCHOLARSHIP FOUNDATION is a nonprofit 501(c)(3) initially conceived by parents of Fusion students. The Foundation was built for the students who could thrive at Fusion, but who simply don?t have the means.

FUSI ON SCH OL ARSH I P.ORG

Fusi on Schol ar sh i p Foun dat i on 2017 Schol ar sh i p Aw ar ds Pr ogr amUnder the Program, three (3) scholarships, each valued at roughly $40,000*, will be awarded to students attending a Fusion Academy middle or high school. One (1) scholarship will be awarded to one (1)

approved student in each region.

Program Guidelines & Priorities

Fusi on Schol ar sh i p Com m i t teeC/O Fusion Scholarship Foundation | 72 Monroe Center, Suite B | Grand Rapids, MI 49503

*Includes 50% match of Foundation's grant by Fusion Education Group.

Appl i cat i on s m ay be dow n l oaded f r om the Fusi on Schol ar sh i p Foun dat i on w ebsi te an d subm i t ted v i a em ai l to j l yn ch@fusi on schol ar sh i p .or g. For quest i on s, con tact Jessi ca Lyn ch at j l yn ch@fusi on schol ar sh i p .or g or 616.301.1221, exten si on 705.

1. W est Coast 2. Cen t r al 3. East Coast

California Illinois Connecticut

Texas Massachusetts

New Jersey

New York

Virginia

Washington, DC

Fusi on Academ y Regi on s

Scholarship applicant must have an Active Inquiry pending with their intended Fusion Academy.  An

Active Inquiry is defined as a prospective family who has inquired through fusionacademy.com or has

called the school.

Applicant?s total family annual income must be under $100,000 as evidenced by the required

Financial Statement (FS) for Financial Aid and Scholarship Services form included in this packet. The

applicant family must be able to self-fund at least 5% of total tuition costs. Currently enrolled students who have experienced a significant change in financial circumstances are welcome to apply

for scholarship funding.

The attached application and FS must be fully completed and submitted to the Fusion Scholarship

Foundation (address below). Application deadline is July 30, 2017 by 4:00 PM.

Scholarship funds will be paid directly to Fusion Academy and not to the student family. Parent(s) or legal guardian(s) are responsible for submitting an invoice for first and second semester

tuition and fees including student ID number and applicable campus information.

Students receiving a scholarship must maintain a 2.5 GPA and a 90% attendance record to remain

eligible for continued funding.

Family members of any Fusion Academy or Fusion Scholarship Foundation board or staff are not

eligible to apply. Donors may not designate scholarships for family members.

2

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1. Student Applicant Please type application.

Last Name: First Name: Middle Initial:

Date of Birth: Gender:

2. Applicant Family Mailing Address

Street:

City: State: Zip:

3. Parent(s) or Legal Guardian(s) Contact Information

Parent or Legal Guardian A Name:

Parent or Legal Guardian B Name:

Street Address: Address same as above.

City: State: Zip:

Primary Phone: Alternate Phone:

Primary Email:

Alternate Email:

4. School Location & History

In which Fusion Academy Region do you live? Please select.

Are you currently attending or have you previously attended Fusion Academy?

If no, how did you learn about Fusion Academy?

Name of school currently attending: Location:

5. Please tell us about your passions, interests and hobbies.

6. Family EssayPlease type an essay using 250-500 words addressing the following topics:1.) Challenges or obstacles you have dealt with in life and how attending Fusion Academy will help you succeed in school

and life. 2.) Describe your experiences in a traditional school setting and why you believe Fusion’s one-to-one instruction will

benefit you.

7. Family IncomeList your Gross Annual Household Income from your 2016 Income Tax Return:(You are also required to submit the Financial Statement (FS) for Financial Aid and Scholarship Services form.)

$

Yes No

Central East Coast West Coast

FAMILY STATEMENT OF ACCURACY (To be completed by parent/legal guardian and/or student applicant.)

I hereby affirm that all the above stated information provided by me is true and correct to the best of my knowledge. I also consent that if chosen as a scholarship winner my picture may be taken and used to promote the Foundation’s scholarship program. (Winner may waive photo due to unusual or compelling circumstances.)

I hereby understand that if chosen as a scholarship winner, according to Fusion Scholarship Foundation policy, I must be present at any potential awards ceremony, event or reception in August 2017 to receive my scholarship award.

I hereby understand that if chosen as a scholarship winner, according to Fusion Scholarship Foundation policy, it is my responsibility to remit to the Foundation the appropriate information for my scholarship to be paid directly to Fusion Academy for my first and second semesters.

I hereby understand I will not submit this application without all required attachments and supporting information. Incomplete applications or applications that do not meet eligibility criteria will not be considered for this scholarship.

Signature of Student Scholarship Applicant: Date:

Signature of Parent/Legal Guardian: Date:

Scholarship Application Checklist

Completed/Submitted Fusion Academy Enrollment Application

Completed Scholarship Application

Completed Financial Statement (FS) for Financial Aid and Scholarship Services

Family Essay Attached

School Transcript(s) Attached

Financial Statement (“FS”) Financial Aid and Scholarship Services 2017 Academic Year

Family members of any Fusion Academy or Fusion Scholarship Foundation board or staff are not eligible to apply. Donors may not designate scholarships for family members. 20170619

Student Legal Name: Last First Middle

Submit this form by the Fusion Scholarship Foundation program deadline of July 17, 2017. FORM MUST BE FILLED OUT COMPLETELY IN ORDER TO BE CONSIDERED.

Please check of one the following:

I/We declare that I/we am/are attaching a Federal Tax Income Return for the year 2016.

I/We declare that I/we am/are not required to file a Federal Income Tax Return for the year 2016. Below is a statement of my/our entire income/support and expenses for the year 2016.

I/We declare that I/we will not file a Federal Income Tax Return for the year 2016. Below is a statement of my/our entire income/support and expenses for the year 2016.

I/We did file a Federal Income Tax Return for the year 2016 but my/our Adjusted Gross Income (AGI) was less than $15,000. Below is a statement of my/our income/support and expenses for the year 2016.

2016 INCOME/SUPPORT RECEIVED FROM: TOTAL ANNUALLY 2016 EXPENSES PAID: TOTAL

ANNUALLY

Scholarships, Federal Financial Aid for Parent(S) $ Housing/Rent $

Grants - Explain: $ Utilities (i.e. electric, water, cable) $

Other Loans (I.E. From Banks, Relatives, Friends, Etc.) $ Cell Phone $

Cash Received From Family/Friends/Others $ Food $

Welfare *Submit Benefit Statement $ Clothing $

Food Stamps $ Medical/Dental Insurance $

Section 8 Housing $ Child Support/Alimony $

Child Support/Alimony $ Vehicle Insurance $

Wages (from employer, cash for labor/services) $ Transportation (car, bus, parking) $

Unemployment Compensation $ Child Care $

Social Security Benefits (parents/children) *Submit 1099 $ Student Loan(s) $

Worker's Compensation $ Tuition - Preschool to Gr. 12 $

Veteran's Benefits $ Tuition - College $

Pension/Ira/Retirement $ Other - Specify: $

Living And Housing Allowances $ TOTAL EXPENSES $

Other - Specify: $

TOTAL INCOME $

Financial Statement (“FS”) Financial Aid and Scholarship Services 2017 Academic Year

Family members of any Fusion Academy or Fusion Scholarship Foundation board or staff are not eligible to apply. Donors may not designate scholarships for family members. 20170619

Expenses paid by another person or business in 2016 (NOT Guardian A or Guardian B on FS Application):

EXPENSE PAID FOR BY AMOUNT Ex: Housing Parents (student's grandparents) $600.00 per month Ex: Child Care Arbor/ResCare $150.00 per week

$ per

$ per

$ per

$ per

$ per

Please explain the family’s living arrangement:

Please explain how the household is supported:

Additional comments about your financial situation:

I/We hereby certify that the information provided herein is complete and correct to the best of my/our knowledge. I/we understand that Fusion Scholarship Foundation may require additional documents in support of my/our child’s application; that it is my/our responsibility to provide such required information and that my/our child’s application shall not be deemed complete until I/we provide such required information.

Parent/Legal Guardian A Signature: Date:

Parent/Legal Guardian A Name (Printed): Phone:

Parent/Legal Guardian B Signature: Date:

Parent/Legal Guardian B Name (Printed): Phone:

SUBMIT COMPLETED FORM WITH APPLICATION TO:

Fusion Scholarship Foundation C/O Fusion Scholarship Foundation | 72 Monroe Center, Suite B | Grand Rapids, MI 49503

This form may be downloaded from the Fusion Scholarship Foundation website and submitted via email to jlynch@fusionscholarship.org. For questions or concerns, contact Jessica Lynch at jlynch@fusionscholarship.org or 616.301.1221, extension 705.