Online Form - Sliding-Fee/Scholarship Request Form

Sliding-Fee/Scholarship Request Form

All information provided is confidential, and your privacy will be protected.

Contact Information:
Name*
First Last
Email*
Phone*
Address*
Street Address Address Line 2 City State ZIP Code
How did you hear about us/who referred you?*
What class are you interested in signing up for?*
Have you attended one of our classes on scholarship before?*
- Yes
- No
Are you interested in a more flexible payment plan or a sliding fee/scholarship?*
- Sliding Fee/Scholarship
- Payment Plan
(please see Payment Plan Agreement form for details)
Sliding Scale Policy:
While we are happy to have people in our classes at any payment level, our scholarship programs are supported with income from our classes and generous donors. In order to maximize the number of people we can serve, we have established the following table based on income and family size. Accepted documentation for income verification: most recent 1040, paystubs for 1 month, disability determination letter, social security award letter, proof of SNAP benefits. Please let us know if there are extenuating circumstances not reflected by this documentation. During your intake conversation, we may use other criteria (such as a serious illness, recent job loss, divorce, or family death) to determine scale percentage

We limit all new applicants to the sliding scale program to one class to begin with. Upon successful completion of this course, you are welcome to sign up for additional classes as desired. However, please only sign up for classes you can commit to attending.

Barring extenuating circumstances, we reserve the right to terminate scholarship eligibility if two or more classes are missed without prior notice/negotiation.

Protecting access to your Voucher Code is your personal responsibility. The sharing of your voucher code for use by anyone else is grounds for immediate dismissal from the Sliding Fee Scholarship program.

Your scholarship information will be held for a year, pending an annual scholarship status review. All information provided is confidential, and your privacy will be protected.
Refund Policy:
No refunds after first two class sessions.
Sliding Scale Calculation Table:

Family Size	0%	10%	20%	40%	60%	80%	100%
1	$12,060	$12,061-14,349	$14,350-16,649	$16,650-21,149	$21,150-25,649	$25,650-30,149	$30,150
2	$16,240	$16,241-19,340	$19,341-22,440	$22,441-28,500	$28,501-34,560	$34,561-40,599	$40,600
3	$20,420	$20,421-23,470	$23,471-26,530	$26,531-34,704	$34,705-42,877	$42,878-51,049	$51,050
4	$24,600	$25,601-29,600	$29,601-32,700	$32,701-42,300	$42,301-51,900	$51,901-61,499	$61,500
5	$28,780	$28,781-33,080	$33,081-37,380	$37,381-48,880	$48,881-60,380	$60,381-71,949	$71,950
6	$32,960	$32,961-37,860	$37,861-42,760	$42,761-55,960	$55,961-69,160	$69,161-82,399	$82,400
7	$37,140	$37,141-42,640	$42,641-48,140	$48,141-63,040	$63,041-77,940	$77,941-92,849	$92,850
8	$41,320	$42,321-47,320	$47,321-53,320	$53,321-69,920	$69,921-86,520	$86,521-103,299	$103,300
9	$45,500	$45,501-52,300	$52,301-59,100	$59,101-77,300	$77,301-99,500	$99,501-113,749	$113,750
10	$49,680	$49,681-57,080	$57,081-64,480	$64,481-84,380	$84,381-104,280	$104,281-124,199	$124,200

I have read, understand, and agree to the Sliding Fee Scholarship Policies:
Income Documentation*
Accepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 8 MB.

Please upload your income verification here.
Date*
MM slash DD slash YYYY
Signature*
Office Use
Verifying Staff Member Initials:
Agreement Good Through:
Voucher Code:

Online Form – Sliding-Fee/Scholarship Request Form

Sliding-Fee/Scholarship Request Form

Contact Information:

Sliding Scale Policy:

Refund Policy:

Sliding Scale Calculation Table:

Office Use

Help Us Thank Our Sponsors

Sliding-Fee/Scholarship Request Form

Contact Information:

Sliding Scale Policy:

Refund Policy:

Sliding Scale Calculation Table:

Office Use

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Help Us Thank Our Sponsors