Champ Hockey Financial Assistance Application Form

Champ Hockey Scholarship Application
Athlete Name*

First NameLast Name
School Grade Level (completed, if summer)*
Summer Pre-Season PrepU14 Fall sessionU16/U19 Winter sessionU16/U19 Spring sessionOther
To be Completed by Parent / Guardian
Parent / Guardian Name

First NameLast Name
Parent / Guardian Email
example@example.com
Please make a brief statement describing why you are in need of financial assistance. *
To be Completed by Guardian
Yes, full-timeYes, part-timeNo, not currentlyOther
What is your occupation / job title? *
Yes, full-timeYes, part-timeNo, not currentlyOther
What is partner's occupation? (N/A if no partner is contributing to your household income) *

What is the combined/total annual household income: Check the appropriate box. *

Rows	Under $20,000	$20,000-$30,000	$30,000-$40,000	$40,000-$50,000	$50,000-$60,000	$60,000 and Up
Income

The amount of assistance is based off a rolling tier. The items listed below are to be transferred from your 1040: (Includes spouse's / legal partner's information is applicable).
Number of Dependents*
Line 6C on 1040, Line 5on 1040 EZ or Line 6C on 1040A.
Adjusted Gross Income*
Line 37 on 1040, Line 4 on 1040 EZ or Line 21 on 1040 A.
Total Income*
Line 22 on 1040 or Line 15 on 1040 A.
List Special Circumstances (If any)
YesNo
By signing this document, I agree that the information is accurate.
Parent / Guardian Name*

First NameLast Name
Parent / Guardian Signature*
Please Note: Financial assistance is not guaranteed. It will be determined based on the viability of your application. Assistance will be given based on the availability of funds and level of need. Please write a descriptive account of why you are requesting financial assistance. This application is confidential. The information on the form will not be disseminated. We will notify applicants of the award amount within 2-4 weeks. Need is the most important priority for the Financial Assistance Program.
Should be Empty:

Champ Hockey Scholarship Application