2025 Count Me In Scholarship Application

1. Guardian Full Name (First and Last) *This question is required.

2. RecTrac Household # (If you already have an established account)

3. Household Member

Space Cell	Full Name	Birthday (mm/dd/yyyy)
Family Member 1	Family Member 1: Full Name	Family Member 1: Birthday (mm/dd/yyyy)
Family Member 2	Family Member 2: Full Name	Family Member 2: Birthday (mm/dd/yyyy)
Family Member 3	Family Member 3: Full Name	Family Member 3: Birthday (mm/dd/yyyy)
Family Member 4	Family Member 4: Full Name	Family Member 4: Birthday (mm/dd/yyyy)
Family Member 5	Family Member 5: Full Name	Family Member 5: Birthday (mm/dd/yyyy)

4. Are there any additional household members? If filing for household, please list all household members who are financially dependent on one or more members of household, including yourself. If applying as individual, just list yourself. If no, skip to the next question.

Space Cell	Full Name	Birthday (mm/dd/yyyy)
Family Member 6	Family Member 6: Full Name	Family Member 6: Birthday (mm/dd/yyyy)
Family Member 7	Family Member 7: Full Name	Family Member 7: Birthday (mm/dd/yyyy)
Family Member 8	Family Member 8: Full Name	Family Member 8: Birthday (mm/dd/yyyy)
Family Member 9	Family Member 9: Full Name	Family Member 9: Birthday (mm/dd/yyyy)
Family Member 10	Family Member 10: Full Name	Family Member 10: Birthday (mm/dd/yyyy)

5. Full Address *This question is required.

6. City *This question is required.

7. State *This question is required.

8. Zip Code *This question is required.

9. E-mail Address This question requires a valid email address.

10. Phone Number

11.

Upload ONE of the following verifications:

IRS Verification Letter
Free Lunch PWC Verification Letter
SNAP Approval Letter

All documentation must include name and date.

File: {{filename}} delete

12. I certify that all the information on this application is true and correct, and that I will or have provided a) A current Prince William County free lunch voucher or b) a current IRS tax statement c) SNAP approval letter.

Please note application submittal does not guarantee approval.

13. Your E-mail Address (to receive a PDF copy of your responses) *This question is required.