Financial Assistance Application Child's Name * First Name Last Name Parent/Guardian Name * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Cell Phone * (###) ### #### Annual Household Income * Requested Assistance Grant * Please detail use of assistance grant * Please provide bills to be paid, if applicable Digital Signature * Please type your full name as your digital signature and check the box below. I agree by typing my signature this is a signed application that is true to the best of my knowledge. * Yes No Thank you for applying for our financial assistance. We will review your application and contact you if we need further information.
