Financial Assistance Application Form

Parent Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Email

example@example.com

Name of student(s) applying for:

Which Program are you interested in?

Please make a brief statement describing why your family is interested in having your student attend The Birch School.

To be Completed by Parent / Guardian

Please give a basic description of the reason(s) you are in need of financial assistance.

What is your occupation / job title?

What is spouse's/partner's occupation? (where applicable)

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

	Under $30,000	$30,000-$50,000	$50,000-$75,000	$75,000 -$100,000	$100,00-$125,000	$125,000 +
Income

INDEXED TUITION

The amount of assistance is based off a rolling tier.

Depending on your income, you can receive a tuition grant of 10%, 20% or 30% off the standard tuition rates.

The items listed below are to be transferred from your 1040: (Includes spouse's information if applicable).

PLEASE NOTE STUDENT REQUIREMENTS TO RECEIVE ASSISTANCE:

Financial Assistance is prioritized for students maintaining overall grades of B or better and with good attendance. (The goal is unexcused absence rate less than 5% - 7 days per school year). If students are not meeting these expectations Financial Assistance may be limited or revoked.

Filing Status*

Tax Year you are using to complete this form:*

Household Size

Number of Dependents*

Adjusted Gross Income*

Line 11 on 1040

Total Income*

Line 9 on 1040

Do you have other children for whom you pay school tuition or daycare?

YesNo

As part of our tuition assistance process, we’d like to understand what monthly amount your family could contribute toward tuition. Please enter the amount that feels manageable for your household.

List Special Circumstances (If Any)

By signing this document, I agree that the information is accurate.

Parent / Guardian Name

First NameLast Name

Parent / Guardian Signature

Please upload documentation to support your request. This may be last year's tax form, recent paystubs, W2's or any other information that you can provide to help make a determination of your financial need. This information remains confidential.

Documentation #1

Documentation #2 (optional)

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 your child is in need of financial assistance.

This application is confidential. The information on the form will not be disseminated.

Our financial assistance committee will meet once a month to allocate funds. the committee will distribute the Financial Assistance funds until they are diminished.

We will notify applicants of the award amount within 2/4 weeks.

Need is the most important priority for the Financial Assistance Program.

The Birch School Financial Assistance Application