FINANCIAL ASSISTANCE APPLICATION
320 East Davis Street
PO Box 1336
Burlington, NC 27216 PH: 336-227-0939
The Holy Comforter Community Playschool admits students of any race, color, national and ethnic origin to all the rights, privileges, programs, and activities generally accorded or made available to students at the school. It does not discriminate based on race, color, national and ethnic origin in administration of its educational policies, admission policies, scholarship and loan programs, and athletic and other school-administered programs.
FINANCIAL ASSISTANCE APPLICATION DATE:
APPLICANT INFORMATION: CHILD’S NAME:
AGE OF CHILD: DATE OF BIRTH:
NUMBER OF DAYS CHILD ATTENDS: (CHECK ONE)
2 DAYS
3 DAYS
PARENTS’ NAMES MAILING ADDRESS: CITY: STATE:
ZIP CODE:
HOME PHONE:
CELL PHONE:
EMAIL ADDRESS: ALL PERSONS LIVING IN THIS HOUSEHOLD: PARENT/ADULT’S EMPLOYER: PARENT/ADULT’S EMPLOYER: NAME:
DATE OF BIRTH:
NAME:
DATE OF BIRTH:
NAME:
DATE OF BIRTH:
NAME:
DATE OF BIRTH:
NAME:
DATE OF BIRTH:
NAME:
DATE OF BIRTH:
NAME:
DATE OF BIRTH:
NAME:
DATE OF BIRTH:
Holy Comforter Community Playschool
FINANCIAL ASSISTANCE APPLICATION
page 1 of 2
Select one (1) of the following: I have filed federal taxes for last year (form 1040). Submit copy. Total amount of household income $ _________________ …or… I did not file federal taxes for last year (Documents showing most recent 30 days of income including pay stubs or documentation of government assistance $
(30 days income) x 12 months =
$
Total annual income …or… My household income has changed since I filed taxes last year. (Attach documents showing most recent 30 days of income including pay stubs or documentation of government assistance.)
$
Monthly income
$
Total annual household income
I certify that the above information is true and complete to the best of my knowledge.
X
Date: _____________
( S ig n a t u r e o f p e r s o n c o m p le t in g f o r m )
OFFICE USE ONLY: Approved: Percentage:
YES
NO
% Through Playschool funding % Responsibility of applicant
Approved by: Date of approval: Holy Comforter Community Playschool
FINANCIAL ASSISTANCE APPLICATION
page 2 of 2
PO Box 1336
Burlington, NC 27216 PH: 336-227-0939
The Holy Comforter Community Playschool admits students of any race, color, national and ethnic origin to all the rights, privileges, programs, and activities generally accorded or made available to students at the school. It does not discriminate based on race, color, national and ethnic origin in administration of its educational policies, admission policies, scholarship and loan programs, and athletic and other school-administered programs.
FINANCIAL ASSISTANCE APPLICATION DATE:
APPLICANT INFORMATION: CHILD’S NAME:
AGE OF CHILD: DATE OF BIRTH:
NUMBER OF DAYS CHILD ATTENDS: (CHECK ONE)
2 DAYS
3 DAYS
PARENTS’ NAMES MAILING ADDRESS: CITY: STATE:
ZIP CODE:
HOME PHONE:
CELL PHONE:
EMAIL ADDRESS: ALL PERSONS LIVING IN THIS HOUSEHOLD: PARENT/ADULT’S EMPLOYER: PARENT/ADULT’S EMPLOYER: NAME:
DATE OF BIRTH:
NAME:
DATE OF BIRTH:
NAME:
DATE OF BIRTH:
NAME:
DATE OF BIRTH:
NAME:
DATE OF BIRTH:
NAME:
DATE OF BIRTH:
NAME:
DATE OF BIRTH:
NAME:
DATE OF BIRTH:
Holy Comforter Community Playschool
FINANCIAL ASSISTANCE APPLICATION
page 1 of 2
Select one (1) of the following: I have filed federal taxes for last year (form 1040). Submit copy. Total amount of household income $ _________________ …or… I did not file federal taxes for last year (Documents showing most recent 30 days of income including pay stubs or documentation of government assistance $
(30 days income) x 12 months =
$
Total annual income …or… My household income has changed since I filed taxes last year. (Attach documents showing most recent 30 days of income including pay stubs or documentation of government assistance.)
$
Monthly income
$
Total annual household income
I certify that the above information is true and complete to the best of my knowledge.
X
Date: _____________
( S ig n a t u r e o f p e r s o n c o m p le t in g f o r m )
OFFICE USE ONLY: Approved: Percentage:
YES
NO
% Through Playschool funding % Responsibility of applicant
Approved by: Date of approval: Holy Comforter Community Playschool
FINANCIAL ASSISTANCE APPLICATION
page 2 of 2
