To be completed by applicant and parent or guardians

A sum of money is set aside each year to assist participants who might otherwise be unable to participate in specific events. If you would like to apply, please fill in the information requested below and return the form to the Executive Director. The Board of Directors ensures confidentiality.

Name(s) of participant: ______________________________________________________________________

__________________________________________________________________________________________

Telephone: ( _______ )__________________________________

Address: __________________________________________________________________________________

City: _________________________________________ State: __________ Zip Code: _______________

Date of Birth: _________________________ Grade in School: ________ Years in NWYO: _________

Requesting program assistance for (please circle all that apply):

Tuition Fees  Retreat  

Fee or Cost of Event $ _______________  Amount you are able to pay $ _______________

Are there any special circumstances you wish the Board to consider?

Number of dependents: _______________  Ages: __________________________________________

Total family income from all sources (please circle):

Under $10,000   $10,000 - $15,000  $15,000 - $20,000

$20,000 - $30,000  $30,000 - $40,000  Over $40,000

Due to limited funds each year, families must apply each season.

This is only an application. You will be notified in writing.

Signature of parent or guardian: _______________________________________________________________