Personal Pricing Application 2014-15
Personal Information (please print)
________________________ _______________ _________________ __________________
Adult #1 Applicant Name
Gender
Cell Phone
Email Address
________________________ _______________ _________________ __________________
Adult #2 Applicant Name
Gender
Cell Phone
Email Address
__________________________________ _____________________ _______ ____________
Adult #1 Street Address
City
State
Zip
__________________________________ _____________________ _______ ____________
Adult #2 Street Address
City
State
Zip
Area of programming you are requesting help for (please circle for each person)
Adult #1
Community Education Enrichment Programs
Community Education Trips
Adult #2
Community Education Enrichment Programs
Community Education Trips
Family Information: (Exclude adults from above list. Please print)
_____________________ _______ __________ _____________ $__________________________________
Child #1 Name
Applying for (please circle)
Gender
Birthdate
Youth Classes
Grade (PreK-12 )
Kids’ Co. Childcare
If applicable, SSI or other regular income for child #1
Kids’ Co. Wrap
Swimming Lessons
Pool Pass
_____________________ _______ __________ _____________ $__________________________________
Child #2 Name
Applying for (please circle)
Gender
Birthdate
Youth Classes
Grade (PreK-12 )
Kids’ Co. Childcare
If applicable, SSI or other regular income for child #2
Kids’ Co. Wrap
Swimming Lessons
Pool Pass
_____________________ _______ __________ _____________ $__________________________________
Child #3 Name
Applying for (please circle)
Gender
Birthdate
Youth Classes
Grade (PreK-12)
Kids’ Co. Childcare
If applicable, SSI or other regular income for child #3
Kids’ Co. Wrap
Swimming Lessons
Pool Pass
_____________________ _______ __________ _____________ $__________________________________
Child #4 Name
Applying for (please circle)
Gender
Birthdate
Youth Classes
Grade (PreK-12 )
Kids’ Co. Childcare
If applicable, SSI or other regular income for child #4
Kids’ Co. Wrap
Swimming Lessons
Pool Pass
*Please answer the following questions when applying to Kids’ Company or Kids’ Co. Wrap.
Total number of days per week: Child #1 _____ Child #2 _____ Child #3 _____ Child #4 _____
Have you applied for assistance at the County Department of Human Services? Yes _____ No _____
Were you denied assistance from the County Department of Human Services? Yes _____ No _____
If denied, please explain why: __________________________________________________________________________________
__________________________________________________________________________________________________________
How many adults listed above are employed? _______
How many adults listed above are attending school on a full-time basis? ________
(Full-time students must submit a copy of their current class schedule with this application)
Please complete both sides
Monthly Total Household Income (Please print - Include proof of income documents with application)
Adult #1
Adult #2
Self-Employment: $__________
Food Stamps $________ Self-Employment: $__________
Gov’t Assistance $___________
Unemployment $______
Gov’t Assistance $___________
Unemployment $______
Child Support $______________
Alimony $____________ Child Support $______________
Alimony $____________
Pension/Retirement $_________
Other $______________ Pension/Retirement $_________
Other $______________
Source:______________
Source:______________
Social Security: $______ Gross Wages: $_____________
Social Security: $______
Gross Wages: $_____________
Food Stamps $________
Total Monthly Household Income: $___________________ (all sources)
If applicable, County Assistance Case #: __________________ Name of County: ____________________________
All income information listed is required to include attached supporting documentation. Failure to do so will result in no review of this
request.
Are there extenuating circumstances you would like us to consider with your application? (please circle) Yes
If yes, please explain here:
Extenuating Circumstance Narrative: (please be clear about the circumstances being considered)
No
Parent/Guardian Narrative: (please explain why this program would benefit you or your child(ren))
By signing below, I certify that the information provided on this application is true and correct. I agree to notify New Prague Area
Community Education in writing of any change in status (e.g. income, work schedule, school schedule, additional scholarships or
change in residency within ten (10) business days of the change. A new form must be filled out and submitted with documentation
annually, as well as when there are changes to family or income. All documents must be dated.
Signature of Applicant: X__________________________________________ Date: ________________________
Without the support of donors, the personal pricing plan would not be possible. One of the most valuable ways we keep donors
committed is to say “thank you”. Our donors have said time and time again that receiving a thank you note from the recipient of their
gift is the most meaningful form of thanks they can receive. Because of this, we ask that you or your child write a thank you note
describing what the program experience has meant to you. Please drop the note(s) off at the Community Education office and we will
pass it on.
FOR OFFICE USE ONLY:
Gross Annual Income: $________________________
Specific Program(s): _______________________
Family Size Total: ___________________
___________________________
_______________________
Approved %: _______________________ Date Approved: ________________
Exception: ____ Yes (attach approval) ______ No
Approved by (print): _______________________________ Approved by signature: ______________________________________________