VA Scholarship Application
Veteran First Name*
Veteran Last Name*
Branch of Service*
Air Force
Army
Coast Guard
Marines
Navy
Discharge Date*
(mm/dd/yyyy)
Phone Number*
Email*
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?*
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?*
You are applying for how many children?*
Please Select…
1
2
3
Student #1
First Name*
Last Name*
Date of Birth*
(mm/dd/yyyy)
Rising Grade (Grade Level for 2020-2021 School Year)*
Current School (School for 2019-2020 School Year)*
Relationship to Veteran:*
Summer at Brentwood
1st Choice
Camp/Course Name*
Date(s)*
(mm/dd/yyyy)
2nd Choice
Camp/Course Name*
Date(s)*
(mm/dd/yyyy)
3rd Choice
Camp/Course Name*
Date(s)*
(mm/dd/yyyy)
Student #2
First Name*
Last Name*
Date of Birth*
(mm/dd/yyyy)
Rising Grade (Grade Level for 2020-2021 School Year)*
Current School (School for 2019-2020 School Year)*
Relationship to Veteran:*
Summer at Brentwood
1st Choice
Camp/Course Name*
Date(s)*
(mm/dd/yyyy)
2nd Choice
Camp/Course Name*
Date(s)*
(mm/dd/yyyy)
3rd Choice
Camp/Course Name*
Date(s)*
(mm/dd/yyyy)
Student #3
First Name*
Last Name*
Date of Birth*
(mm/dd/yyyy)
Rising Grade (Grade Level for 2020-2021 School Year)*
Current School (School for 2019-2020 School Year)*
Relationship to Veteran:*
Summer at Brentwood
1st Choice
Camp/Course Name*
Date(s)*
(mm/dd/yyyy)
2nd Choice
Camp/Course Name*
Date(s)*
(mm/dd/yyyy)
3rd Choice
Camp/Course Name*
Date(s)*
(mm/dd/yyyy)
Please send a confirmation email to the address below: