Directions: Please fill out the information below. Attach proof of income (copy of most recent check stub, etc.) All information will remain confidential and will only be reviewed by the Youth Assistance Fund Coordinator.

Participant Information

Name of Child________________________________________________

Full Address ____________________________Phone____________________

Birth Date ____________School Name_____________Grade Level __________

Parent/Legal Guardian Information

Name_________________________________________________________

Occupation ________________Number of Children in Household______________

If unemployed, Source of Income:_____________________________

Total Gross Monthly Income:_________________________________

Program Desiring Assistance In:_____________________________

If there is any additional information you would like to provide (participant's statement, extenuating circumstances, etc.) that would assist us in determining need, please use space provided or attach any additional sheets if necessary.

I certify that the information provided in this application is true and complete. I understand that false statements on this application shall be cause for disqualification from funding assistance.

Parent/Legal Guardian Signature _________________________Date ___________________