Johnston Urbandale Soccer Club

Johnston Urbandale Soccer Club Karen Coaldrake Financial Assistance Fund APPLICATION - Page 1 The parents or guardians of any JUSC player may apply for assistance to pay club fees in order for their child to participate in the sport of soccer. All applications will be treated with respect and in a CONFIDENTIAL manner. To be considered for financial assistance you must complete this form and show proof of household income. Attach Federal 1040 Form and final paycheck stub or W2 to this application. Incomplete applications may be returned and may be given no consideration for the season. Applications must be received by July 7th, 2017. Please read Financial Assistance Fund Policy and Procedures before completing application. If you are applying for assistance for more than one child, please list the name and age group of each child. Applicant Information Date of Application _________________________________________________ JUSC Player Name __________________________________________________ Age Group _________________________________________________________ Parents(s) Name(s) ____________________________________________________________________ Home Address, City, State, Zip__________________________________________________________ e-mail address_______________________________ e-mail address____________________________ Home Phone ____________________ Cell ____________________ Work _______________________ # of Dependent Children _________________________ Number of children in college _____________________ Number of children in club soccer and where _____________________________________________ How can you support club activities? ____________________________________________________ _________________________________________________________________________________ What extracurricular activities is your child in? ____________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Employment Information Are you currently employed? _____Yes ____No Employer’s Name __________________________________________________ Address __________________________________________________________ Position held _____________________________________________________ Length of time with company _________________________________________ Is your spouse/significant other employed? ____Yes ____No Employer’s Name ___________________________________________________ Address __________________________________________________________ Position held ________________________________________________________ Length of time with company _________________________________________ Do you receive unemployment? ____Yes ____ No Do you own or rent your home ___________________ Number of persons living in household ________________________________ Financial Data Applicant must provide acceptable means of proof of household income (attach federal 1040 form and final paycheck stub or W2 to this application) Your monthly gross income $_____________________ Spouse income $__________________________ Child support $___________________________ Other Income $___________________________ Source ____________________________________ Total monthly income $________________________ If you receive State or Federal aid, please list all (food stamps, medical aid, free school lunch program, etc.) __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________

Johnston Urbandale Soccer Club Karen Coaldrake Financial Assistance Fund APPLICATION - Page 2

Please describe any special circumstances you have and why you should be considered for financial assistance: _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ Upon acceptance of financial assistance, applicant makes a one year commitment to the team and agrees to assist with volunteer club functions as needed. If these commitments to JUSC are not fulfilled, I will be financially responsible for the annual fees. I fully understand that should my employment or financial position change that I will contact JUSC of such change. __________________________________ Parent(s)/Guardian(s) Signature _______________________ Date __________________________________ Parent(s)/Guardian(s) Signature _______________________ Date Please mail all requested materials for financial assistance to: JUSC Financial Assistance Committee-CONFIDENTIAL P.O. Box 31069 Johnston, IA 50131 Questions? Please e-mail the JUSC Club Treasurer at [email protected]. --------------------------------------------------------------------------For Club Use Only: Team Name__________________________ Age Group _________________ Boys_____ Girls_____ Approved: ___________________________ Denied:__________________________ Comments: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Amount Approved for Players Fees: _____________________________________________________ Date :______________________________________________________________________ Approved By:

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