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Membership Scholarship Application Information & Guidelines ed. 7/12

The Salvation Army Kroc Center is pleased to provide access to our facility and our programs. It was Joan Kroc’s vision and expectation that all individuals have equal opportunities to develop and discover their natural gifts and talents. The Kroc Center is a world-class facility designed to do just that! We are delighted that you are interested in active membership at the Kroc Center. Please read carefully and follow these step-by-step instructions to complete your Membership Scholarship Application. 1. This packet includes the Membership Scholarship Information Form, Agreement Form, and Application Form. 2. Please read the Membership Scholarship Agreement Form, sign and date at the bottom of the page. 3. Completely fill out the Membership Scholarship Application Form, sign and date at the end. 4. Attach copies of all income verification to the application. Household income includes the gross income of anyone who earns and/or receives income and lives in the household. Acceptable forms of proof are dated within the last 30 days: pay stub, unemployment or worker’s compensation income, TANF/FI, SNAP/Food Stamps, child support or alimony. VA benefits may be dated within the last 90 days. Social Security retirement, disability or SSI may be dated within the last year. For self-employment please provide the first two pages of your last Federal tax return. 5. Mail the completed information, which includes the Membership Scholarship Agreement Form, the Membership Scholarship Application, and copies of proof of income to: Kroc Center Attn: Membership Scholarship 1833 Broad Street Augusta, GA 30904 Or, you may seal the documents in an envelope marked “Membership Scholarship” and drop them off at the Kroc Center Welcome Desk. 6. Incomplete applications (including those missing proof of income) will not be processed. Only complete applications can be screened and considered to receive a Membership Scholarship. 7. Staff members may contact you with questions; please give accurate and neatly written phone and email contact information. 8. You will be notified about the final status of your Membership Scholarship Application by mail. 9. If you receive a Membership Scholarship, you must bring your award letter and your photo identification to the Kroc Center within 30 days of the date of the letter to enroll.

The Salvation Army Ray & Joan Kroc Corps Community Center - P.O. Box 921 - Augusta, GA 30903 - Phone 706.364.KROC (5762) - www.krocaugusta.org


Please keep this sheet for your reference — Sign and return the other copy of the Membership Scholarship Agreement ed. 7/12

The Salvation Army Kroc Center is pleased to provide financial aid for access to our facility and our programs. It was Joan Kroc’s vision and expectation that all individuals have opportunities to develop and discover their natural gifts and talents. The Kroc Center is a world-class facility designed to do just that! We are delighted that you are interested in participating in our programs. Please read carefully. If you have any questions please contact The Salvation Army First Stop Family Service Center at 706-9228330 for more information. 1. All Kroc Center scholarship and income-based membership applications are confidential. You agree to not discuss your application or award with others. 2. Making an application does not guarantee you will receive a scholarship. Slots are limited. Management reserves the right to put you on a waiting list or deny your application if space is not available. 3. Membership scholarships are awarded based on demonstrated financial need, a personal interview, interest in pursuing selfimprovement goals, and willingness to participate in case management and to regularly use the Kroc Center and its amenities. 4. If your household is unable or not interested in participating in required case management and programs, you may want to contact the Member Services Department to ask about the Income Based Membership program, which has different requirements. 5. Membership scholarships are for the full cost of your approved household’s membership for six months. Membership scholarships cover basic participation fees but do not cover meals or food, additional supplies, uniforms or athletic clothing, or similar expenses. A membership scholarship does not give access to Kroc Center programs requiring tuition. 6. Membership scholarships are awarded on a rolling admission basis. Applications are accepted at any time; however, you may be placed on a waiting list if slots are not currently available. Processing can take from 2 to 6 weeks. Applicants will be notified by phone or mail about their status. 7. Program scholarships for classes or camps are separate from a membership scholarship application or award. 8. Membership scholarships do not automatically renew but recipients may request recertification for an additional 6 months. 9. You must report and provide proof of all household income. Failure to list income is considered fraud. 10.Please also provide general household expense information but do not attach copies of your bills. 11.Any information found to be incomplete, fraudulent, or false will result in this application and any scholarships issued from it being cancelled. Additional penalties related to participation at the Kroc Center may be given at the discretion of management. 12.You agree to participate in scheduled case management meetings, pursue your goal plan, and use the Kroc Center regularly as stated in your goal plan. Missing meetings or attendance without a documentable excuse may result in the loss of your membership scholarship. If you lose your scholarship you must wait at least 6 months before you can apply for another membership scholarship. 13.Any status changes in your household or income must be reported immediately to your Case Manager. 14.The scholarship program is designed to help your household reach your goals, grow personally, and become self-sufficient. Scholarships are meant to be a path and encouragement for growth, not a permanent way to access Kroc Center membership. 15.The Salvation Army Kroc Center reserves the right to modify the Membership Scholarship program and guidelines at any time.


Membership Scholarship Agreement ed. 7/12

The Salvation Army Kroc Center is pleased to provide financial aid for access to our facility and our programs. It was Joan Kroc’s vision and expectation that all individuals have opportunities to develop and discover their natural gifts and talents. The Kroc Center is a world-class facility designed to do just that! We are delighted that you are interested in participating in our programs. Please read carefully. If you have any questions please contact The Salvation Army First Stop Family Service Center at 706-9228330 for more information. 1. All Kroc Center Scholarship and Income Based membership applications are confidential. You agree to not discuss your application or award with others. 2. Making an application does not guarantee you will receive a scholarship. Slots are limited. Management reserves the right to put you on a waiting list or deny your application if space is not available. 3. Membership scholarships are awarded based on demonstrated financial need, a personal interview, interest in pursuing selfimprovement goals, and willingness to participate in case management and to regularly use the Kroc Center and its amenities. 4. If your household is unable or not interested to participate in required case management and programs, you may want to contact the Member Services Department to ask about the Income Based Membership program, which has different requirements. 5. A Membership Scholarship is for the full cost of your approved household’s membership for six months. The Registration fee is waived for Membership Scholarship recipients. Membership Scholarships do not cover meals or food, additional supplies, uniforms or athletic clothing, or similar expenses, nor do they give access to Kroc Center programs requiring tuition. 6. Membership scholarships are awarded on a rolling admission basis. Applications are accepted at any time; however, you may be placed on a waiting list if slots are not currently available. Processing can take from 2 to 6 weeks. Applicants will be notified by phone or mail about their status. 7. Program Scholarships for classes or camps are separate from a Membership Scholarship application or award. 8. Membership scholarships do not automatically renew but recipients may request recertification for an additional 6 months. 9. You must report and provide proof of all household income. Failure to list income is considered fraud. 10. Please also provide general household expense information but do not attach copies of your bills. 11. Any information found to be incomplete, fraudulent, or false will result in this application and any scholarships issued from it being cancelled. Additional penalties related to participation at the Kroc Center may be given at the discretion of management. 12. You agree to participate in scheduled case management meetings, pursue your goal plan, and use the Kroc Center regularly as stated in your goal plan. Missing meetings or attendance without a documentable excuse may result in the loss of your Membership Scholarship. If you lose your scholarship you must wait at least 6 months before you can apply again. 13. Any status changes in your household or income must be reported immediately to your Case Manager. 14.The Membership Scholarship program is designed to help your household reach goals, grow personally, and become selfsufficient. Scholarships are meant to be a path and encouragement for growth, not a permanent way to access Kroc Center membership. 15.The Salvation Army Kroc Center reserves the right to modify the Membership Scholarship program and guidelines at any time. By signing below you agree that you understand and accept the Kroc Center Membership Scholarship Guidelines. Signature: ____________________________________________ Date: ___________________________ Print Name:____________________________________________ Optional information: How did you hear about the Kroc Center membership scholarship? _________________________________________________ _______________________________________________________________________________________________________ (For statistical purposes only ) How many members of your household consider themselves: ETHNICITY Hispanic _____ Non-Hispanic _____ RACE Asian _____ American Indian or Alaskan _____ Black or African American _____ White _____

Pacific Islander _____ Multi-Racial _____ Other _____

The Salvation Army Ray & Joan Kroc Corps Community Center - P.O. Box 921 - Augusta, GA 30903 - Phone 706.364.KROC (5762) - www.krocaugusta.org


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CONFIDENTIAL

Kroc Center Membership Scholarship Application SECTION I – APPLICANT INFORMATION (Head of Household) ed. 7/12 Date stamp Are you currently a Kroc Center member? __No __ Yes (if yes, mark type below) __ Standard __ Gold __Income-Based __ Scholarship Name (First, MI, Last): _____________________________________________________________________________________ Mailing Address: _____________________________________________City: ______________ State: _____ Zip: ___________ Main Phone: ______________________________ Alternate Phone(s): ______________________________________________ Email: _________________________________________________________________ Birthdate: _______________________ Household Status (choose one): __ Single __ Married __ Widowed __ Divorced __ Significant Other __ Roommate SECTION II – OTHER HOUSEHOLD MEMBERS List all people living in household with applicant. Please indicate if children are foster children. More space available on back. Name (First, MI, Last)

Age

Sex

Relationship to Applicant

Birthdate

SECTION III – HOUSEHOLD FINANCES Please give complete and accurate information. Attach copies of proof of income. More space available on back. Which household members receive income and what type? _______________________________________________________ Employer name: __________________________________ Hours worked/Week: ____________ Hourly Wage: $_____________ Employer name: __________________________________ Hours worked/Week: ____________ Hourly Wage: $_____________ Monthly Household Income

Monthly Household Expenses

Wages & Side Jobs:

$

Food:

$

SSI, SSA, Disability:

$

Transportation:

$

Unemployment or Workers’ Comp:

$

Child Care:

$

TANF/ FI:

$

Medical:

$

SNAP/Food Stamps:

$

Housing and Utilities:

$

Child Support/Alimony:

$

Loan payments:

$

Other, please explain:

$

Other, please explain:

$

Total:

$

Total:

$

APPLICATION CONTINUES ON BACK FOR OFFICE USE ONLY: Date Received & by: ____________________ Complete? ___ Action? _________________________ Phone Asmnt/Interview Date: __________ Date Cmplt:__________ ___ Recommend ___ Reject/Withdraw ___ Counsel/Refer Reasons: ___________________________________________________________________________________________________ Date Approved & by: _____________________ Date Mailed/Given & by: _____________________ Notes: _____________________________________________________________________________________________________ The Salvation Army Ray & Joan Kroc Corps Community Center - P.O. Box 921 - Augusta, GA 30903 - Phone 706.364.KROC (5762) - www.krocaugusta.org


SECTION IV – PARTICIPATION REQUEST How will your household benefit from a Kroc Center Membership Scholarship and participation in case management and classes or programs? What goals will you pursue? Attach no more than one page if needed.

ADDITIONAL INFORMATION Please use the space below for any additional information that did not fit in other areas of the form.

This application and all required documentation are confidential information and will be used only by authorized staff for the purpose of processing Kroc Center Membership Scholarship applications. By signing below you agree that all information provided is accurate and complete. Any information found to be incomplete, fraudulent, or false will result in this application and any scholarships issued from it being cancelled. Additional penalties related to participation at the Kroc Center may be given at the discretion of management. Signature of Applicant: ___________________________________________________ Date: ___________________________ Please complete all sections and attach copies of proof of income. Incomplete applications cannot be processed.

The Salvation Army Ray & Joan Kroc Corps Community Center - P.O. Box 921 - Augusta, GA 30903 - Phone 706.364.KROC (5762) - www.krocaugusta.org

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