Student Assistance Program
Assistance Request Form
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is this request for?
*
Please Enter the Name of the Student that you are requesting assistance for:
*
First Name
Last Name
Please Enter the Name of the Student that you are requesting assistance for (Type N/A if Applicable):
*
First Name
Last Name
Please Enter the Name of the Student that you are requesting assistance for (Type N/A if Applicable)
*
First Name
Last Name
Please Enter the Name of the Student that you are requesting assistance for (Type N/A if Applicable):
*
First Name
Last Name
What is the amount requested per youth?
*
What is the total amount requested?
*
Are students/youth listed above:
*
SLYC Registered
Non-Registered
Please upload invoices/receipts of the items/activities that you are seeking assistance for?
*
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I, undersigned, agree with the following statements:
*
I am the parent of youth(s) listed in this request.
I certify (promise) that all information on this form is true and that all income is reported.
I understand that the request can only be up to $50 per registered youth (up to $25 per unregistered youth), per academic year, if funding is available.
I understand that organization officials may verify (check) the information.
I understand that it could take up to one week for requests to be reviewed and approved.
I understand that if I purposely give false information, my request will be denied and my child(ren) could lose access to future funding, awards, events and/or activities.
Date
*
-
Month
-
Day
Year
Date
Signature
*
Submit
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