SlidingScaleApplication

SLIDING SCALE APPLICATION FOR DARING DAUGHTERS' PROGRAMS

At Daring Daughters INC., we are committed to making our programs accessible to all individuals, regardless of financial circumstances. To ensure equity, we offer a sliding scale fee structure based on your financial situation. Please fill out this application accurately and completely to determine your eligibility. Applicant Information

Full Name

Date of Birth

Date

Phone Number

Email Address

example@example.com

Address

Which Daring Daughters program are you applying for Please specify

Program Information Which Daring Daughters program are you applying for? (Please specify):

Please indicate your total household income:

Are you currently receiving any financial assistance? (e.g., SNAP, WIC, Medicaid, housing assistance, etc

Why do you want to participate in this program

Do you have any special circumstances that you would like us to consider

To verify your eligibility for the sliding scale, please provide ONE of the following

Most recent tax return (first page only) Two most recent pay stubs Proof of financial assistance (e.g., SNAP or Medicaid card)

Consent and Agreement By signing below, I certify that the information provided in this application is true and accurate to the best of my knowledge. I understand that providing false information may disqualify me from participating in Daring Daughters'

Signature

Date

Date Received

Date

Reviewed By

Sliding Scale Fee Assigned

Notes

Thank you for your application. Our team will review your submission and notify you of your eligibility and fee adjustment within 7-10