MTME SCHOLARSHIP APPLICATION
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Candidate Information
Name
*
First
Last
Birthday
MM
1
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12
DD
1
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YYYY
2026
2025
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1931
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1928
1927
1926
1925
1924
1923
1922
1921
1920
How did you hear about the scholarship program?
FHSR event
Service provider
Website
Social media
Name of service provider
Name of referring institution/school
Parent/Guardian Information
*
First
Last
Phone
*
Email
*
Relationship to applicant
*
Residence
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Information regarding the applicant
Hearing loss level
Device used (if any)
Music class location preference
Schedule preference
Please tell us anything else you'd like to share
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A Sound Investment in Deaf and Hard of Hearing Children
Thank you so much for your donation!
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Contribution Amount:
*
Contributor -
$100.00
Supporter -
$250.00
Friend -
$500.00
Champion -
$1,000.00
Donor - Your Amount -
$0.00
Other Donation Amount
Please Direct My Donation To:
*
FHSR's Area of Greatest Need
Music Programming
Clinical and Community Outreach
Loaner Hearing Aid Program
Education Coordinator Program
Make this donation in honor or memory of a family member, friend or colleague.
Make this donation in honor or memory of a family member, friend or colleague.
Tribute Information. Please complete the following information with regard to the person or persons you wish to honor or remember.
In Honor Of
In Memory Of
Person(s) In Honor or In Memory of
*
Message
From
*
How often do you want to make this donation?
*
One-Time Gift
Monthly
Annually
Recipient Information
Please complete the following information with regard to the person or persons you wish to receive notification of your gift.
Recipient Name
*
First
Last
Recipient Address
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Recipient Email
Your Information
Name
*
First
Last
Address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone
*
Email
*
My Company Will Match This Gift!
My company will match this gift.
Company Contact Name
*
First
Last
Company Contact Phone
Company Contact Email
Comment or Message Regarding your Matching Program
Stripe Credit Card
*
Card
Name on Card
Thank you!
Thank you so much for your gift to support FHSR's goals! You just made a big difference in the lives of the families and kids we serve. Our entire community thanks you!
Gift Amount
$0.00
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