Financial Assistance Request

Attendees of the Rise Afterschool Program may apply for financial assistance to cover a portion of their monthly tuition. Applicants must have an annual gross salary of less than $60,000. Please complete the information and documentation below and we will respond within 3-5 business days. If need further assistance, please email britney.vidal@movementfoundation.org

Parent/Guardian Name

First Name

Last Name

Primary Email

Primary Phone

(###)

###

####

Program Site

Eastland

Freedom

Northwest

Southwest

Information for Child 1

Child 1 Name

First Name

Last Name

Child 1 Grade

Child 1 Gender

Information for Child 2

Child 2 Name

First Name

Last Name

Child 2 Grade

Child 2 Gender

Information for Child 3

Child 3 Name

First Name

Last Name

Child 3 Grade

Child 3 Gender

Information for Child 4

Child 4 Name

First Name

Last Name

Child 4 Grade

Child 4 Gender

Income Information

Number of Household Members

Monthly Income

Annual Income

AFDC Per Month (if applicable)

SNAP Per Month (if applicable)

Child Support Per Month (if applicable)

Social Security Per Month (if applicable)

Pension Per Month (if applicable)

Other Income Per Month (if applicable)

Please list any extenuating circumstances for us to consider when reviewing your application.

If your child has previously received financial assistance, how do you feel the program has helped your child?

I authorize the Rise Afterschool Program to share my story.

Acknowledgment

I acknowledge that if I am offered and accept Financial Assistance, I understand that my portion of the child care program cost must be paid on time and my account must be kept current. Failure to comply with the payment polices outlined in the program handbook may jeopardize future financial assistance.

By checking this box I acknowledge that all information provided on this form is accurate to the best of my knowledge

Financial Assistance Request

Please let us know if you have any questions about our Afterschool program or employment opportunities!