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Annual Authorization Grade Disclosure Form


Date: __________________

I ____________________ who is the parent/guardian of my son/daughter

______________________, hereby give  authorization to disclose their

end of school year grades to the authority of MBP Healthy Living Youth  

Scholarship Program for the sole purpose and use of awarding scholarship 

dollars on behalf of the student. I understand that their grades will be in  

 possession of the program and will not be used for any purpose other

than awarding scholarship dollars.

Print Name: __________________________________


 Please complete this authorization form and mail to MBP Healthy Living Youth Scholarship Program at 331 Woodland Dr. Edenton, NC 27932. If you have any questions, please feel free to email us at  mbpscholarshipprogram@gmail.com or call 1-800-743-0929 

MBP Healthy Living for Youth Scholarship Program
2126 Lakeview Ste 195 Ypsilanti, MI 48198