Sliding Scale Application

Sliding Scale Application
Please note: Sliding scale assistance is offered based on available funding and is not guaranteed. Applications are reviewed based on financial need and program availability. We encourage you to apply early before program registration periods.
Participant (Student) Name*

First NameLast Name
Participant (Student) DOB*

MonthDayYear
Date
Parent/Guardian Name (if applicable)

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Program Applying for:
Input program or session name
Household and Income Information
Total number of people in household:*
Total Annual Household Income:*
EmploymentSelf-EmploymentSocial Security/DisabilityRetirement/PensionChild Support/AlimonyUnemploymentPublic AssistanceOther
REQUIRED DOCUMENTATION

Please attach ONE of the following documents to verify your household income:
- Most recent federal tax return (Form 1040) - first two pages only
- Two most recent pay stubs for all employed household members
- Social Security, disability, or retirement benefit statements
- Unemployment benefit documentation
- SNAP/food stamp eligibility letter
- Oregon Health Plan (OHP) enrollment documentation
- Free/reduced lunch program qualification letter
- Letter from employer stating wages
REQUIRED DOCUMENTATION*

Cancelof
- CONSENT & AUTHORIZATION
  
  Privacy Statement and Financial Verification Consent:
  
  I understand that Solid Ground Equine Assisted Services requires the requested financial information to determine eligibility for reduced program fees. I hereby authorize Solid Ground to:
  1. Verify the information provided on this application
  2. Request additional documentation if necessary
  3. Store this information securely for the purpose of determining financial assistance eligibility
  I understand that:
  - All financial information will be kept confidential and used solely for the purpose of determining sliding scale eligibility
  - Financial records will be securely stored for a period of three (3) years and then securely destroyed
  - Only authorized staff members will have access to this information
  - No information will be shared with third parties without my explicit written consent, except as required by law
  - I have the right to request access to my information at any time
  - Providing false information may result in the termination of financial assistance
    I am required to notify Solid Ground of any significant changes to my financial situation
  I certify that all information provided is true and complete to the best of my knowledge.
- Signature*
  
  Clear
- Should be Empty:

Sliding Scale Application

Household and Income Information

REQUIRED DOCUMENTATION