Social Equity Form

Social Equity Discount Application for The Leela School

Helping ensure equitable access to our services
Privacy Notice & Oregon Law Compliance: This information is collected solely to determine eligibility for our social equity discount program, which is designed to increase access to services. Under Oregon law (ORS 659A), we do not discriminate based on race, color, religion, sex, sexual orientation, gender identity, national origin, marital status, age, disability, familial status, source of income, or domestic violence survivor status. All demographic information is collected voluntarily for program evaluation and to ensure we serve diverse communities. This information is kept confidential and will not be shared with third parties or used for any discriminatory purposes.

This entire form is voluntary and no questions are mandatory.
Name

First NameLast Name
E-mail
example@example.com
Phone Number

Area CodePhone Number
Gender Identity (Optional):

WomanManNon-BinaryTransgenderPrefer not to answerOther (please specify)
If you selected other please specify here:
Financial Information

This information helps us determine sliding scale pricing. All income information is kept strictly confidential.
Number of people in your household:
Total annual household income (before taxes):
I am currently experiencing financial hardship due to circumstances such as job loss, medical expenses, or other crisis

YesNo
Would you like to further explain your financial situation to us?
Demographic Information (Optional - for program tracking purposes)

This information is collected voluntarily to help us ensure our programs are reaching diverse communities and to track program effectiveness. You may select multiple options or choose not to answer.
Race/Ethnicity (check all that apply):

American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or Other Pacific IslanderWhitePrefer not to answerOther (please specify)
If you selected Other please specify here:
Military Service
Are you a veteran or active military service member?

VeteranCurrently active dutyNo military service
Additional Circumstances
Please check any that apply to your household:

Full-time studentSenior citizen (65+)I or someone in my household has a disability that creates additional financial burdenSingle parent householdCurrently unemployedHealthcare workerEssential workerNon-profit organization employeeTeacher or education worker
Please describe any other circumstances that should be considered for the social equity discount:
Certification
I certify that the information provided in this application is true and complete to the best of my knowledge*

Yes
I consent to the collection and use of this information for determining eligibility for the social equity discount program*

Yes
Should be Empty:

Social Equity Discount Application for The Leela School

Financial Information

Demographic Information (Optional - for program tracking purposes)

Military Service

Additional Circumstances

Certification