Scholarship Application 2014

SCHOLARSHIP APPLICATION 2014 DATE: / /

CHILD NAME:

PARENT NAME:

DAY TIME PHONE:

Fill out budget worksheet on back side and transfer totals below

TOTAL INCOME $ TOTAL EXPENSE $ = (DEFICIT)/SURPLUS $

Explain any unusual circumstances or reasons why you cannot afford the regular tuition based on our sliding scale?

I understand that the Salvation Army depends on charitable contributions to subsidize its programs and to provide scholarship funds. Therefore, I will inform The Salvation Army if my financial situation improves and do everything I can to pay the regular fee based on my income. I understand that failure to report a significant change in my financial position would constitute fraud and could result in the termination of my child from the After School/Summer Day Camp Program. I understand that if the scholarship is granted it will be reviewed every other month and the scholarship rate can be adjusted and/or can be done away with at any time for review. I also understand that I must provide a copy of proof of income in the form of pay stubs as well as copy of all my bills before the scholarship can be processed.

/ / Parent’s Signature Date ******FOR OFFICE USE ONLY****** Application reviewed by: Date: / / ( )Approved ( )Denied Reason: AFTER SCHOOL RATES: Normal Sliding Scale Fee: $ 35.00 Parent Pays: $ SUMMER CAMP RATES: Normal Sliding Scale Fee: $ 65.00 Parent Pays: $______SCHOLARSHIP AMOUNT RECVD: After School $______Summer Camp $______BUDGET WORKSHEET 2014

Please fill out as accurately as possible. Decision will be based on information given. Please provide paperwork to verify data on this sheet.

MONTHLY INCOME

Total salary/wages (After taxes) $ Food Stamps $ AFDC $ Social Security $ Veteran’s Benefits/Pension $ Other Pension/Unemployment/Workman’s Comp $ Alimony/Child Support $

Total Income $

MONTHLY EXPENSES

Rent/Mortgage $ Electricity $ Gas $ Water/Sewer $ Phone $ Food (Cash & Food Stamps) $ Misc. Household Items/Clothing $ Car Upkeep/Transportation $ Car Payment $ Car Insurance $ Medical Expense (Doctor, Drugs) $ Medical Insurance $ Other Insurance $ School Fees $ Alimony/Child Support $ Child Care (Do not include Salvation Army Program) $ Loans/Credit Card Payment (List) $

Total Expenses $