Beta Cohort Scholarship Application - AccountableHero Support Coaching

For Individual Applicants:

Full Name:	{"type":"text","name":"__generic11","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}
Age / Grade:	{"type":"text","name":"__generic12","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}
Parent or Guardian Name & Contact Info:	{"type":"text","name":"__generic13","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}
School Name:	{"type":"text","name":"__generic14","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}
City / State:	{"type":"text","name":"__generic15","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}
Do you qualify for free or reduced lunch?	Select1. Yes2. No{"type":"select","name":"__generic16","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Select\n1. Yes\n2. No"}

Do you receive SNAP, Medicaid, TANF, WIC, or other government assistance? (Check all that apply)
SNAP Medicaid TANF WIC Other Government Assistance{"type":"checkbox","name":"__generic17","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please check at least one item.","options":"SNAP\nMedicaid\nTANF\nWIC\nOther Government Assistance"}

Financial Assessment

Please describe your (or your school’s) current financial circumstances that make paying the full program cost a challenge.
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Have (or your organization) applied for outside funding to support enrichment or mentorship programming in the last 12 months?

If yes, please describe the funding source and outcome.
{"type":"textarea","name":"__generic20","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","height":80,"placeholder":""}



What portion of the program fee, if any, are you able to cover at this time?
Select1. None2. Up to $1,0003. $1,000–$2,5004. Over $2,500{"type":"select","name":"__generic21","width":30,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Select\n1. None\n2. Up to $1,000\n3. $1,000–$2,500\n4. Over $2,500"}



Would a payment plan (3–9 months) make the program more accessible to you? 
Select1. Yes2. No{"type":"select","name":"__generic22","width":30,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Select\n1. Yes\n2. No"}



Is there anything else you’d like us to understand about your financial situation?
{"type":"textarea","name":"__generic23","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","height":80,"placeholder":""}

Environmental & Cultural Impact

For Organizations / Schools:

Describe the community your students come from. What challenges do they face?
{"type":"textarea","name":"__generic24","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}



How does your school currently support the emotional, cultural, or leadership development of girls of color?
{"type":"textarea","name":"__generic25","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}



Why is a culturally responsive mentorship program important to your students right now?
{"type":"textarea","name":"__generic26","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}



How would Tilled Soil complement or expand your current programming?
{"type":"textarea","name":"__generic27","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}



Do you have a designated staff member who would serve as a cohort point of contact?
{"type":"textarea","name":"__generic28","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}

For Individual Applicants:
What are some of the biggest challenges you face at home, school, or in your community?
{"type":"textarea","name":"__generic29","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}



What does your cultural or racial identity mean to you?
{"type":"textarea","name":"__generic30","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}



Why do you want to participate in the Tilled Soil mentorship program?
{"type":"textarea","name":"__generic31","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}



How do you think this experience would help you grow personally, emotionally, or academically?
{"type":"textarea","name":"__generic32","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}

Program Readiness & Commitment

Is your school able to commit to the full 9-month cohort duration (virtual/in-person sessions, activities, and check-ins)?

Select1. Yes2. No{"type":"select","name":"__generic33","width":30,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Select\n1. Yes\n2. No"}

Do you have consistent access to the internet or space to participate (home or school-based)?	Select1. Yes2. No{"type":"select","name":"__generic","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Select\n1. Yes\n2. No"}
If no, explain:	{"type":"text","name":"__generic","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}

How will you ensure participation is consistent and meaningful for yourself or your students?
{"type":"textarea","name":"__generic36","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","height":80,"placeholder":""}



Would you be willing to share periodic updates, testimonials, or photos of your journey for impact reporting purposes?

In your own words, what would receiving this discount or scholarship mean to you or your community?
{"type":"textarea","name":"__generic38","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","height":80,"placeholder":""}

Optional Supporting Documents (Highly Encouraged)

Letter of recommendation (from counselor, teacher, principal, or community leader)
Pick an image...{"type":"image","name":"__generic39","width":null,"value":"","size":"Normal","validation":"","validationMessage":"Please provide an image for this item.","maxlength":1,"placeholder":"Pick an image..."}



Most recent school profile (for organizations)
{"type":"textarea","name":"__generic40","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","height":80,"placeholder":""}



A brief video or audio clip explaining your story and vision (2 minutes max)

Submission & Next Steps

Once submitted, your application will be reviewed by the Tilled Soil Scholarship Committee. You will receive a notification of your eligibility in 10 business days.