Pleasant Green Afterschool & Camp Financial Assistance form

Pleasant Green UMC Afterschool & Summer Camp

Financial Assistance Application
To apply for financial assistance, please complete this form and submit it to Pleasant Green Afterschool 3005 Pleasant Green Rd. Durham, NC 27705 or pleasantgreenafterschool@gmail.com.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Student Name
Parent Names
Mailing Address
Email
example@example.com
Phone
Format: (000) 000-0000.
Briefly explain your reasons for requesting financial assistance for the PG AfterschoolSummer Camp program
How many family members live in your home?
Adults?
Children?
What is your family income? (include all sources)
Amount per YEAR
Amount per MONTH
Father's Place of Employment
Phone
Format: (000) 000-0000.
Mother's Place of Employment
Phone
Format: (000) 000-0000.
I confirm the information above is true and authorize Pleasant Green Afterschool to verify the accuracy of this application. I understand that a new application will need to be submitted per year/semester.
ParentGuardian Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Pleasant Green Afterschool & Summer Camp Program 3005 Pleasant Green Rd. Durham, NC 27705 ~ pleasantgreenafterschool@gmail.com
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