Financial Aid Application For Child Form (Page 2 of 2) in pdf

Financial Aid Application - For Child

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Single Parent

Two Parent Family

Total # of family dependents ___________ Ages____________________________

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Total Annual Income:

$0 - $22,000

$22,001 - $35,000

$35,001 - $50,000

$50,001 - Over

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DSS or other Scholarship Case # __________________

Mother’s/Guardian’s Occupation__________________________________________

Father’s/Guardian’s Occupation__________________________________________

We reserve the right to request a W-2 as verfication of your income reported.

Cost of Program:

$_____________

Troop Share of Cost:

$_____________

Parent Share of Cost:

$_____________

Amount of Request:

$_____________

Please indicate any circumstances which make it necessary to seek this financial scholarship, such as ill-

ness, unemployment, unusual expenses, family responsibilities, etc.

This information is confidential.

______________________________________________________________________________________________________

I certify that the information provided is accurate and complete to the best of my knowledge.

Signature of Parent/Guardian______________________________________________________ Date_______________

For Office Use Only:

Total Cost of program:

$_____________

This application has been approved in the amount of:

$_____________

D.S.S. or Other Scholarship Case #_____________

$_____________

Balance Due:

$_____________

Processed by: ____________________________________________________________ Date: ___________________

Girl Scouts of Suffolk County • 442 Moreland Road, Commack, NY 11725 • (631) 543-6622 • gssc.us

Financial Aid Application For Child Form Page 2