Individual and 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:

CanoeingIndoor Rock ClimbingOutdoor Rock ClimbingWhitewater RaftingSnowshoeingCross Country SkiingRock 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

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 StampsHousing Subsidy(Section 8, etc.)MedicaidSchool Free/Reduced Lunch ProgramWaivered ServicesWIC

Please indicate if any of the following apply to you:

UnemployedSingle ParentWe have a special needs family memberActive duty or retired military

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

Individual/Family Financial Aid Application

Household Information

Any Additional Information

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