LSRP Application for Assistance

Application for Assistance with Learning Support for Students

This application is for evaluation and educational support for school-aged children--of single-parent OR single-income, families--with learning challenges.
Contact Information

Parent(s)/Head-of-Household Information
Parent 1*

First NameLast Name
Current Employer?
Parent 2

First NameLast Name
Current Employer?
Home Phone#

Area CodePhone Number
Cell Phone#

Area CodePhone Number
E-mail address?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How many dependents live in the home?
Any aging parents or other relatives living with you? Include them in this number.
How many are children?

Student Information

Tell us about the student who needs the learning support.
Full Name

First NameLast Name
Birthdate

MonthDayYear
School
Current Grade
School District
Briefly describe your child's struggles in school:
Briefly describe remedies you've tried, including working with tutors, teachers, counselors, and special education administrators:

Monthly Income and Expenses
Tell us about the things you can accomplish if assistance is provided:
Wages
Child Support
Social Security
SSI/D
Pension
Foster/Adopt Subsidy
Food Stamps
Total Monthly Income
Rent/Mortgage
Gas/Oil
Electric
Water/Sewage
Garbage
Car Payment & Insurance
Phone, Cable, Internet for home
Mobile phones
Medical co-pays & prescriptions
Credit card bills
Total Monthly Expenses
We will need a copy of your most recent IRS Form 1040. We need only the pages that show your dependents and your adjusted gross income. You may upload a copy or provide it at your interview. Thank you.
Attach your file here:

Upload a File

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Confidentiality: Independent Family Resource Group will maintain the highest standards regarding your personal information. All information will be held in the strictest confidence unless required by law or in order to secure the funds requested.

By submitting this application I agree that the information provided on this form is true and accurate, and that I will update IFR Group of any changes in income, expenses, or household composition as it relates to my request for assistance.
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Application for Assistance with Learning Support for Students