Financial Assistance – Boys & Girls Club of La Plata County

Boys & Girls Club of La Plata County Financial Assistance Application

Falsification of Any Information Will Result in Permanent Disqualification for Assistance.

Incomplete Applications Will Not Be Processed.

Processing will take 5 business days.

GENERAL INFORMATION

First Child Name (required*):

Child Age (required*):

Child DOB (required*):

Second Child Name:

Child Age:

Child DOB:

Third Child Name:

Child Age:

Child DOB:

Fourth Child Name:

Child Age:

Child DOB:

Fifth Child Name:

Child Age:

Child DOB:

Telephone:

Street Address:

City:

State:

Zip:

Date:

SUPPORT INFORMATION

List all persons who provide a source of income for this child, including parents, stepparents, grandparents, other relatives, or any other provider or guardian. Attach a copy of the most recent pay stub. Report gross income.

1. Name (required*):

Relationship (required*):

Phone (required*):

Place of Employment (required*):

Employer’s Phone:

Gross Income (Before taxes) $:

WeeklyBi-WeeklySemi-MonthlyMonthlyOther

2. Name:

Relationship:

Phone:

Place of Employment:

Employer’s Phone:

Gross Income (Before taxes) $:

WeeklyBi-WeeklySemi-MonthlyMonthlyOther

3. Name:

Relationship:

Phone:

Place of Employment:

Employer’s Phone:

Gross Income (Before taxes) $:

WeeklyBi-WeeklySemi-MonthlyMonthlyOther

4. Name:

Relationship:

Phone:

Place of Employment:

Employer’s Phone:

Gross Income (Before taxes) $:

WeeklyBi-WeeklySemi-MonthlyMonthlyOther

OTHER INCOME/SUPPORT

List all other sources of income each month (and amounts) and attach a copy of any determination letter or letters to substantiate

Social Security $:

Child Support $:

Unemployment $:

TANF $:

Other $:

Free/Reduced Lunch (Yes/No):

We do not receive any additional income or support(Yes/No):

TOTAL INCOME FROM ALL SOURCES

Total monthly income for this family $:

Total yearly income for this family $:

Number of people in this household:

Number of children in this household:

OTHER INFORMATION

Has this/these child(ren) attended the Boys & Girls Club before?
YesNo

If yes, when?:

Please attach copy of most recent pay stub(s) and proof of other income by clicking "Upload": .png, .jpg, jpeg, .pdf, .doc files types allowed. 15mb total.

Is there any other information you want us to know about that might help our determination?

Your email