*
Required
VA Scholarship Application
Veteran First Name
*
required
Veteran Last Name
*
required
Branch of Service*
Air Force
Army
Coast Guard
Marines
Navy
Discharge Date
*
required
(mm/dd/yyyy)
Phone Number
*
required
Email
*
required
How did you hear about this program?*
from the VA Greater Los Angeles Healthcare System
at another VA Program/Facility
online
friend
Did your child(ren) participate in Summer at Brentwood last year?*
Yes
No
If yes, please describe your experience and the impact of the program on your family.
If no, what do you hope to gain from the Summer at Brentwood experience?
Are you currently enrolled in an on-campus program (i.e. Compensated Work Therapy, Domiciliary, New Directions, etc.)*
Yes
No
If yes, which one?
*
required
Are you part of an off-campus program or a patient in the VA Greater Los Angeles Healthcare System (Out Patient Treatment, GPD, HUD-VASH, SSVF, etc.)? *
Yes
No
If yes, which one?
*
required
You are applying for how many children?
*
required
Please Select…
1
2
3
Student #1
First Name
*
required
Last Name
*
required
Date of Birth
*
required
(mm/dd/yyyy)
Rising Grade (Grade Level for 2020-2021 School Year)
*
required
Current School (School for 2019-2020 School Year)
*
required
Relationship to Veteran:
*
required
Summer at Brentwood
1st Choice
Camp/Course Name
*
required
Date(s)
*
required
(mm/dd/yyyy)
2nd Choice
Camp/Course Name
*
required
Date(s)
*
required
(mm/dd/yyyy)
3rd Choice
Camp/Course Name
*
required
Date(s)
*
required
(mm/dd/yyyy)
Student #2
First Name
*
required
Last Name
*
required
Date of Birth
*
required
(mm/dd/yyyy)
Rising Grade (Grade Level for 2020-2021 School Year)
*
required
Current School (School for 2019-2020 School Year)
*
required
Relationship to Veteran:
*
required
Summer at Brentwood
1st Choice
Camp/Course Name
*
required
Date(s)
*
required
(mm/dd/yyyy)
2nd Choice
Camp/Course Name
*
required
Date(s)
*
required
(mm/dd/yyyy)
3rd Choice
Camp/Course Name
*
required
Date(s)
*
required
(mm/dd/yyyy)
Student #3
First Name
*
required
Last Name
*
required
Date of Birth
*
required
(mm/dd/yyyy)
Rising Grade (Grade Level for 2020-2021 School Year)
*
required
Current School (School for 2019-2020 School Year)
*
required
Relationship to Veteran:
*
required
Summer at Brentwood
1st Choice
Camp/Course Name
*
required
Date(s)
*
required
(mm/dd/yyyy)
2nd Choice
Camp/Course Name
*
required
Date(s)
*
required
(mm/dd/yyyy)
3rd Choice
Camp/Course Name
*
required
Date(s)
*
required
(mm/dd/yyyy)
Please send a confirmation email to the address below: