BGCWSA Hardship Scholarship Application (EFF

Hardship Scholarship Application

The Boys & Girls Clubs of Waynesboro, Staunton, & Augusta County makes the best effort possible in helping children and families utilize Club programs. Financial assistance may be available to eligible individuals* to enroll your child in our Afterschool or Summer Camp programs.

Fill this application out completely and return with proof of income and expenses for a total of one month for all adults in the household. Please note that Hardship Scholarship awards are contingent on availability of funds and it may take up to one week for a decision to be made for your request.

Hardship Scholarship requirements:

Individual must provide the Club with updated verification income and expenses, if requested during scholarship period

Individual must prove there is a need for reduced cost./scholarship.

Individual must acknowledge that reduced cost (Hardship Scholarship) is contingent on approval, may be time limited, and must be reapplied for once the approval period expires. Scholarships are not approved automatically.
Club Site
ParentGuardian Name
First/Last Name of Members you are requesting a scholarship for
List All Other Household Members
Total Number of ALL persons in Household
Financial Info: Input the ($) dollar amount of what you receive or pay each month for the income and expense areas below. If you do not receive income or do not have an expense for any listed, please input a 0.
Employment
Rent
Utilities
Social Security
Phone
Car Payment
Disability
Insurance
Other
Describe
Other
Describe
Other
Describe
Other
Describe
Other
Describe
Other
Describe
Other
Describe
Other
Describe
Please note that verification of income and expenses may be required with this application and/or during the scholarship period.
Total Monthly Expenses
Additional Application Info: 1. Describe the hardship preventing you from paying the full amount (your story may help us connect your need to a donor):
1 Describe the hardship preventing you from paying the full amount your story may help us connect your need to a donor
2. Anticipated duration of the hardship: 3. Check the session(s) you're requesting hardship for: [ ] Afterschool ]Summer 4. Current Weekly Payment Fee: $per week/per child 5. Hoped-for Weekly Payment Fee: $per week/per child 6. If you're currently enrolled, what is your account's current balance? $
7 Share any other details that may help inform our decision
8. Would you like to volunteer 2 hours per week, or other opportunities (ie. special events), if the scholarship is awarded? [] YesNo (answering no will not impact your application status) Signature: By signing below, I am verifying that all information given is true and accurate. If information is determined to be false, reduced cost services will be canceled/denied. I authorize BGCWSA to verify any information provided. Submitting a hardship scholarship request does not guarantee approval or authorization of the requested amount. I understand that I am responsible for current fees until an approval or denial document is received.
ParentGuardian SignatureDate

Clear
DATE COMPLETED APPLICATION RECEIVED

MonthDayYear
Date
RECEIVED BY
DATE REVIEWED BY CEO

MonthDayYear
Date
BY
DECISION REASON
IF APPROVED, NEW WEEKLY RATE:
STAFF SIGNATUREDATE

Clear
Should be Empty:

Financial Info: Input the ($) dollar amount of what you receive or pay each month for the income and expense areas below. If you do not receive income or do not have an expense for any listed, please input a 0.

IF APPROVED, NEW WEEKLY RATE: