GFMHSF Financial Assistance Application - Gabe Fleming Memorial Hockey Scholarship Fund

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NOTE: You will not be able to save this application, please make sure you are prepared with the following items before starting this application*

Child Applicant for Participation in Questions

Parent/Guardians for Participation in Statement of Need

Applicant

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Telephone Number

Parent/Guardian

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Telephone Number*

Email*

Applicant Information

Age*

Please enter a number from 1 to 99.

Grade Entering in the Fall*

Please enter a number from 1 to 12.

Number of years playing hockey*

Please enter a number from 0 to 12.

Learn to Play Program*

Not Applicable

Learn to Play - Session #1 October

Learn to Play - Session #2 January

League Playing Level*

Not Applicable

6u Mini-Mite

8u RWB

10u Squirt

12u PeeWee

14u Bantam

High School League

Hockey Association*

Ames Minor Hockey Association

Cedar Rapids Youth Hockey Association

Iowa City-Coralville Youth Hockey Association

Des Moines Youth Hockey Association

Dubuque Youth Hockey Association

Mason City Youth Hockey Association

Quad City Hockey Association

Sioux Center Hockey Association

Siouxland Youth Hockey Association

Lakes Area Hockey Association

Waterloo Youth Hockey Association

Number of years playing in your local association*

Please enter a number from 0 to 12.

The following questions are an important part of the application scoring process and are weighted at 35% of the overall score. The child applicant should answer each question completely, with an age appropriate response that is at least 3-5 sentences in length. If needed, it is okay for a parent or guardian to help a younger child answer the questions.

LOVE OF THE GAME - Why do you enjoy playing hockey? What specific aspects of the game do you find most exciting or fulfilling?*

SPORTSMANSHIP - What does sportsmanship and fair play mean to you? This could include how you supported another player on or off the ice.*

MINDSET/POSITIVE CHARACTER - How do you handle challenges or setbacks in hockey, and how does this mindset extend to your everyday life?*

MINDSET/POSITIVE CHARACTER - Describe a fun and positive experience you've had with your hockey team outside of regular practices and games.*

COMMUNITY SUPPORT/LEADERSHIP - Aside from playing, how do you contribute positively to your community? This could include activities with your school, neighborhood, or other groups you are involved in.*

COMMUNITY SUPPORT/VISIONARY - If you could use your passion for hockey to make a positive impact in your community, what would you do?*

SELF-MANAGEMENT - How do you balance school, family, and hockey commitments in your daily schedule?*

The parent or guardian of the child applicant must answer the following question. The requested information is important to the application scoring process and is weighted at 65% of the total score.

Please explain why you are applying for financial assistance for your child. (All responses are kept confidential)*

I certify that the information provided in this Application is accurate, and I give authorization to the Gabe Fleming Memorial Hockey Scholarship Fund to verify the information contained within this Application. Deliberate misrepresentation of material facts in this Application may be cause for disqualification. I understand that awards of financial assistance are granted through a confidential Board of Trustee process based upon outlined criteria, and there is no guarantee made regarding the awarding of financial assistance or the amount of any award. I also understand that the Fund’s financial assistance awards are determined annually, and that I must apply each year for financial assistance consideration.

Signature of Parent or Guardian*

As the Parent and/or Legal Guardian of , I hereby authorize the Gabe Fleming Memorial Hockey Scholarship Fund (“the Fund”), and its Board Members, agents and/or representatives, to use my child’s image and name in all forms and media, for publicity and/or recognition purposes. Consequently, the Fund may publish materials and photographs, use my child’s name, and make reference to my child in any manner that the Fund deems appropriate in order to promote the Fund.

I waive the right to inspect or approve versions of my child’s image used for publication or the written copy that may be used in connection with the images. This authorization is continuous and may only be withdrawn by my specific rescission of this authorization.

I hereby release the Fund, its Board Members, agents and representatives, from all claims, demands and causes of action that may result from use of this authorization.

I am the parent or guardian of the minor named above. I have the legal right to consent to, and do consent to, the terms and conditions of this release.

Parent/Guardian Name

First Last

Parent/Guardian Address

Street Address Address Line 2 City State ZIP Code

Parent/Guardian Signature*