Rush Jackson and Orthopaedic Rehab Specialists Financial Assistance Request Form 2016-17 Player Name: ____________________________________ Age Group (ex: U12 Boys):________________ Years Played within Rush:_____________ Parent 1 Name:____________________________________ Address:_______________________________________________________________________________ Cell Phone:___________________________ Email:___________________________________________ Parent 2 Name:__________________________________ Address:________________________________________________________________________________ Cell Phone:___________________________ Email:___________________________________________ Employment Parent 1 Currently Employed? Yes No Occupation:_________________ Employer:_________________ Parent 2 Currently Employed? Yes No Occupation:_________________ Employer:_________________ Income Annual Gross Income (combined if two parent income):_____________________________ Household Members (list names and ages):______________________________________________________ __________________________________________________________________________________________ Financial Assistance Matrix (used to determine level of assistance) Part A: Age Group and Annual Fee Part B: Requested Percentage of Assistance U15-U19: $999 U13-14: $1,399 U11-12: $1,399 U9-10: $999 U8: $599
Calculate Total Club Fee Capable of Paying: $ _________ Club Fee from Part A x _________ Requested Percentage of Assistance from Part B (ex: 25 % assistance = .75) = _________ Requested Total Club Fee to be Paid by Family/Guardian (Example for u14 boy with 25% assistance: $1,399 x .75 = $1,049.25) Other forms needed by Rush Jackson: 1. On a separate page, briefly explain the reason(s) for your request. 2. Copy of your 2015 tax return and current proof of income form.
How to apply: 1. Completed applications need to be turned in at Club Registration evening on June 23rd. Please place your application and tax return in a manila or mailing envelope with the player’s name and “Rush Jackson SF” on that envelope. 2. Applications will be reviewed and families will be contacted regarding their financial assistance by June 28th, 2016. a. Online registration and initial payment (20% deposit) is due by June 30 th so be ready to register soon after receiving scholarship notice. 3. If you have more than one child in the Rush Jackson Soccer Club and would like financial assistance for each child, please use one form for each child. Other requirements for families receiving financial assistance: 1. Volunteer at club/team events a. Spring Clean-Up Day at Marino’s Park b. Rose City Soccer Tournament c. Tryout weekend 2. Community Service activities (as announced by Club Director) Note from Rush Jackson Financial Aid is NOT guaranteed. An email will be sent to your family by June 28th, 2016 notifying you of the level of support you will receive. All club fees will be collected after the club has responded with the level of financial aid your family will receive – do not make online payment until the club confirms scholarship amount rewarded. A payment plan will be offered to your family outlining the amount of money due, along with when it is due. Failure to meet the minimum monthly payments, and to attend sessions and/or games regularly may result in loss of assistance and/or removal from the program. All information submitted and any financial assistance granted will be kept strictly confidential by the officers of the Rush Jackson Soccer Club. Family Pledge to Rush Jackson I declare the above personal and financial information is accurate and I will submit my most recent federal income tax form and current proof of income form. I understand that receiving financial assistance is a privilege and pledge to have my child at all team activities with soccer as a priority over other athletic activities, and pledge for my family and/or I to volunteer at club events (tryouts, Rose City Soccer Tournament, etc.) as assigned by the club director. Failure to honor commitments may result in loss of assistance and/or removal from the program. I also recognize the scholarship may cover partial fees and I am responsible for paying the remaining balance, and I am responsible for non-club expenses (personal travel, extra events/expenses outside club fees, uniforms, tournaments ref fees, etc.) Financial assistance recipients must notify the club directors of their intentions for the 2017-18 soccer year (leaving for a new club, remaining with the club, not playing soccer, etc) in writing by May 15, 2017. Failure to do so could result in the forfeiture of any future financial assistance. Parent(s) signature:______________________________________ Date:__________________