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: ______________________________________________