Financial Assistance Application

Please complete this application and return to the Director. You must provide a copy of your latest Federal tax return, your most recent pay stub(s) and any other documentation you feel may be pertinent to your application. Your application and financial information will be kept confidential. Please fill out the following individual or family information (even if there is only one income). Income qualification based on sliding scale limits does not guarantee that scholarships will be awarded. Please be aware that there are limited dollars available for distribution and are distributed to those who demonstrate the greatest need.

I am requesting scholarship help with:

The Echelon Academy Day School

Extended School Year

Summer Camp

High Flyers, After School Homework Club

Applicant's Full Name

Home Address

City

Zip Code

Home Phone

Email Address

Employer

Employer Phone

Employer Address

City

Zip Code

Spouse/Partner's Full Name

Home Address

City

Zip Code

Home Phone

Email Address

Employer

Employer Phone

Employer Address

City

Zip Code

List the first and last name of all children under the age of 22, their age and the program for which funds are being requested:

Financial Statement

Income:

Applicant's Family Gross Salary:

Other Income (alimony, trust, interest, rental income, etc.):

Total Income:

Expenses

Rent/Mortgage:

Household Expenses (food, transportation, clothing, utilities):

Other: (please explain in area provided, below):

Total Expenses:

Net Income (Total Income - Total Expenses):

Explanation for "Other" Expenses:

Brief Explanation for need of scholarship assistance:

What do you feel you could pay (Monthly)?:

If yes,

Name:

Date:

Amount (Monthly):

*I acknowledge that all of the information on this form is, to the best of my knowledge, accurate and complete.

(1) Applicant Name*:

Date:

(2) Applicant Name:

Date:

Thanks for submitting!