---

FINANCIAL ASSISTANCE APPLICATION

Applicant(s) Parent/Guardian (if under 18) (required)

Address (required)

City (required)

State/Zip (required)

Home Phone (required)

Daytime Phone (required)

Mobile Phone (required)

Email Address (required)

---

Family Information

Number of people in family (required)

Number of ADULTS in family (required)

Number of CHILDREN in family (required)

Names and Birthdates of Children (Child 1 Name, Birthdate / Child 2 Name, Birthdate / Child 3 Name, Birthdate, etc.) (required)

Monthly Family Income (required)

Our family currently recieves

SSI

Food Stamps

Disability

Public Assistance

Rental Assistance

Other

---

Class I Want To Enroll In

Desired Activity/Program

Activity #

I hereby certify that all provided information and documentation is true and correct to the best of my knowledge. (required)

YES

Your Signature (required)

Confirm e-Signature

Review Electronic Records and Signatures Policy (required)

Read our Electronic Record and Signature Disclosure

I agree to use electronic records and signatures

There was a problem saving your submission. Please try again later.

Please wait while your submission is being saved...

Submitting...Submit

Thank you, your submission has been received.

Proof of Income: Do not mail information; please bring the following with you to the interview.

1. Copies of the most recent one month’s worth of consecutive pay stubs for any parent who lives in the household. (For Example, If you get paid weekly, there should be four pay stubs: bi-weekly, two pay stubs, etc.)

2. Proof of residency (Utility bill/lease agreement)

3. Current tax return (not W-2)

4. Verification of any other source of income (child support, disability, public assistance, unemployment, etc.)

---

Aplicación para Ayuda Financiera

Aplicante(s) Padre/Guardián (si es menor de 18) (required)

Dirección (required)

Ciudad (required)

Estado/Código postal (required)

Teléfono de Casa (required)

Teléfono en el dia (required)

Teléfono Celular (required)

Correo Electrónico (required)

---

Información de la Familia

Numero de Familia (required)

Adultos de Familia (required)

Niños de Familia (required)

Nombres y fecha de nacimiento de los Niños (Niño 1-Nombre, Fecha de nacimiento / Niño 2-Nombre, Fecha de nacimiento / Niño 3-Nombre, Fecha de nacimiento, etc.) (required)

Nuestro familia recibe actualmente

SSI

Estampillas de comida

Deshabilitad

Asistencia Publica

Asistencia con la renta

Otro

---

Clase en la que deseo ser Inscrito:

Nombre del Participante (required)

# de Actividad (required)

Nombre de la Clase/Actividad (required)

Yo certifico que toda la información y documentación proveída es verdadera y correcta para el mejor de mi conocimiento. (required)

Si

Your Signature (required)

Confirm e-Signature

Review Electronic Records and Signatures Policy (required)

Read our Electronic Record and Signature Disclosure

I agree to use electronic records and signatures

There was a problem saving your submission. Please try again later.

Please wait while your submission is being saved...

Submitting...Submit

Thank you, your submission has been received.

Prueba de ingresos: No enviar la siguiente información por correo, favor de traerla el día de su entrevista

1. Copias de los talones de cheques mas recientes (consecutivos) del ultimo mes, por cada padre viviendo en casa. (Por ejemplo: si usted recibe pago por semana, deberán de ser 4 talones de cheque; si usted recibe pago cada dos semanas, deberán de ser 2 talones de cheque.)
2. Prueba de Residencia (Recibo de utilidades/Contrato de renta)
3. Declaración de Impuestos actuales (No formas W2)
4. Verificación de cualquier otra fuente de ingreso. (sustento de niños, deshabilitad, asistencia publica, desempleo, etc.)