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Individual and Family Financial Aid Application - Splore
Individual and Family Financial Aid Application
Please use this form if you are applying for yourself, an individual or as a family.
Individual/Family Financial Aid Application
Name
Address
City
State
Zip
Phone
Email
How did you hear about us?
*
Word of mouth, social media, print ad, etc.
Let us know your trip activity:
Canoeing
Indoor Rock Climbing
Outdoor Rock Climbing
Whitewater Rafting
Snowshoeing
Cross Country Skiing
Rock On!
What goals/outcomes do you want to experience through Splore’s activities?
Total Trip Cost:
*
Requested dates:
Let us know the date or range of dates you want to book.
What specific amount of financial aid (in dollars) are you requesting?
*
Please let us know either a percentage or dollar amount of financial aid you would need to participate on the trip you have chosen. Please keep in mind that we have a limited amount of financial aid, requests increase each year, and we try to assist as many families as we can with our financial aid funds.
What is your household's monthly gross income?
*
2014 or 2015 tax return OR if you receive SSI just upload a copy of your most recent disbursment
*
please upload a copy of your most recent tax return or paystub to be considered for our financial aid program
Household Information
Family Member #1
Name, gender, age and disability.
Family Member #2
Name, gender, age and disability.
Family Member #3
Name, gender, age and disability.
Family Member #4
Name, gender, age and disability.
Family Member #5
Name, gender, age and disability.
Family Member #6
Name, gender, age and disability.
Who will be participating on the trip(s)?
Please write the first names of those in your household who are likely to participate.
Are you able to transport yourself and your group to this activity?
Please check the programs in which you currently participate
Food Stamps
Housing Subsidy(Section 8, etc.)
Medicaid
School Free/Reduced Lunch Program
Waivered Services
WIC
Please indicate if any of the following apply to you:
Unemployed
Single Parent
We have a special needs family member
Active duty or retired military
Any Additional Information
Are there other circumstances of which you would like to make us aware?
By typing my name below, I represent and agree that all information is true and correct.
Date
Verification
Please enter any two digits with no spaces (Example: 12)
*
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please leave it blank
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