BACK TO SCHOOL SUPPLIES: APPLICATION


Please complete the following brief application. We will sort out applications by school and then work with the counselors of each school to choose the most qualified candidates. Deadline to submit the application is June 21st, by noon EST. Please visit www.DRMINIYAR.com to find our locations or visit our Facebook page: www.facebook.com/Dr.Raj.Miniyar

Parent’s Name:

Mailing Address:

Cell Number:

E-mail:

Have you applied for any assistance with any other program? If so, please give details.

1. First Child

Name:

Age:

Grade:

2. Second Child

Name:

Age:

Grade:

3. Third Child

Name:

Age:

Grade:

4. Fourth Child

Name:

Age:

Grade:

Please describe in details about why you are in need of the assistance?