Online Financial Assistance Application Applicant's Name*Partner / Spouse's NameChild's Custodian (if different)Enrolling/Enrolled Child's NameDOBEnrolling/Enrolled Child's NameDOBHousehold InformationTotal Additional Household MembersPlease choose number012345Household Member #1 NameAgeRelationshipHousehold Member #2 NameAgeRelationshipHousehold Member #3 NameAgeRelationshipHousehold Member #4 NameAgeRelationshipHousehold Member #5 NameAgeRelationshipNeed for Care(Please feel free to submit letter outlining circumstances)Applicant's Employer / SchoolOccupation / Field of StudyEmployer / School AddressPhonePartner's Employer / SchoolOccupation / Field of StudyPartner's Employer / School AddressPhoneFinancial InformationEmployer subsidized child care?YesNoThird Pary Assistance?YesNoThird Party Assistance Case #Salaries (Gross, before deductions)Child SupportOther Income (alimony, disablity, grants, etc)Third Party Assistance Co-PayTotalFinancial Assistance/Scholarship Acceptance I agree.I understand that I may be asked to provide previous year's federal & state tax returns or most current pay stub(s) as verification of income. I understand any falsification of the above statements will result in termination of my financial assistance and enrollment at Fruit & Flower. I understand that if I have a change in income, employment, schooling, or living arrangements, I must restate this application. Consent to share. I agree.I understand Fruit & Flower may share my story to solicit donations for our scholarship funds, pending Financial Assistance/Scholarship acceptance. Signature*Your Name*CommentsThis field is for validation purposes and should be left unchanged.
