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Program 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 participating in our programs. Please read carefully and follow these step-by-step instructions to complete your Program Scholarship Application. 1. This packet includes the Program Scholarship Information Form, Agreement Form, and Application Form. 2. Please read the Program Scholarship Agreement Form, sign and date at the bottom of the page. 3. Completely fill out the Program Scholarship Application Form, sign and date at the end. Use this example for Section IV: Name (First, MI, Last) Jane Doe

Age 11

Session Spring 2012

Which Camp, Class, or League? Beginning Pottery

John Doe

9

Summer 2012

Camp sessions 1 through 4

John Doe

9

Fall 2012

Upward Basketball

4. Attach copies of all income verification to the application. Household income means 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 Program Scholarship Agreement Form, the Program Scholarship Application, and copies of proof of income to: Kroc Center Attn: Program Scholarship 1833 Broad Street Augusta, GA 30904 Or, you may seal the documents in an envelope marked “Program 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 considered for a Program 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 Program Scholarship application by mail. 9. If you receive a Program Scholarship, you must bring your award letter and your photo identification to the Kroc Center within 10 days of the date on the letter to enroll. You must complete enrollment no later than 3 days before the session starts.

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 Program 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 Children and Youth Program Department representative at 706-922-1533 for more information. 1. All Kroc Center Scholarship and Income Based 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 offer an alternative to your first choice, put you on a waiting list, or deny your application if your requested program is full. 3. Program Scholarships are awarded based on income. Depending on your household income and size you may be offered a scholarship requiring you to pay a portion of the regular tuition fee for the class or program. 4. Scholarships cover basic participation fees but do not cover additional craft or art supplies, uniforms or athletic clothing, or similar expenses. A Program Scholarship does not give day pass, guest, or membership access to Kroc recreation facilities. 5. Program scholarships are awarded on a first come, first served basis. For all programs except camps you may apply no earlier than one month prior to the session start date and no later than 10 days prior to the session start date. Summer camp application dates begin March 1 and end 10 days before the final session starts. School holiday camp applications begin 2 months prior to the camp and end 1 week prior to the camp. 6. Each individual is allowed up to 6 program scholarship sessions per year. For example, taking beginning pottery and advanced guitar during the same months equals 2 sessions. Summer and school holiday camps do not apply to this limit. 7. You must report and provide proof of all household income. Failure to list income is considered fraud. 8. Please also provide general household expense information but do not attach copies of your bills. 9. 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. 10.You agree to attend all classes or meetings of any program for which you receive a Program Scholarship. Recipients who miss more than 2 classes or meetings without a documentable excuse may complete their current program session but will have a 6 month suspension before they can apply for another program scholarship. 11.The Salvation Army Kroc Center reserves the right to modify the Program Scholarship program and guidelines at any time.


Program 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 Children and Youth Program Department representative at 706-922-1533 for more information. 1. All Kroc Center Scholarship and Income Based 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 offer an alternative to your first choice, put you on a waiting list, or deny your application if your requested program is full. 3. Program Scholarships are awarded based on income. Depending on your household income and size you may be offered a scholarship requiring you to pay a portion of the regular tuition fee for the class or program. 4. Scholarships cover basic participation fees but do not cover additional craft or art supplies, uniforms or athletic clothing, or similar expenses. A Program Scholarship does not give day pass, guest, or membership access to Kroc recreation facilities. 5. Program scholarships are awarded on a first come, first served basis. For all programs except camps you may apply no earlier than one month prior to the session start date and no later than 10 days prior to the session start date. Summer camp application dates begin March 1 and end 10 days before the final session starts. School holiday camp applications begin 2 months prior to the camp and end 1 week prior to the camp. 6. Each individual is allowed up to 6 program scholarship sessions per year. For example, taking beginning pottery and advanced guitar during the same months equals 2 sessions. Summer and school holiday camps do not apply to this limit. 7. You must report and provide proof of all household income. Failure to list income is considered fraud. 8. Please also provide general household expense information but do not attach copies of your bills. 9. 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. 10.You agree to attend all classes or meetings of any program for which you receive a Program Scholarship. Recipients who miss more than 2 classes or meetings without a documentable excuse may complete their current program session but will have a 6 month suspension before they can apply for another program scholarship. 11.The Salvation Army Kroc Center reserves the right to modify the Program Scholarship program and guidelines at any time. By signing below you agree that you understand and accept the Kroc Center Program Scholarship Guidelines. Signature: ____________________________________________ Date: ___________________________ Print Name:____________________________________________

Optional information: How did you hear about the Kroc Center program 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

Program Scholarship Application SECTION I – APPLICANT INFORMATION (Head of Household) ed. 7/12 Are you currently a Kroc Center member? __No __ Yes (if yes, mark type below) Date stamp __ 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 Rec’d & by: _________________ Complete? ___ Action? ________________ Date Cmplt: ________ Qualified? N Y Amount? 50% $5 History OK? _____ History notes: ____________________________________________ Total Cost of Request: $_____________ Amount to be Paid by Participant: $_____________ Amount of Assistance: $_____________ Date Approved & by: ________________ Date Mailed & by: ________________ Date Lead informed & 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 List each household member for whom you want to apply for a program scholarship, their age, the session by date, and which camp, early drop off/late pick up, program, class, sports league, or team you request for a scholarship. Name (First, MI, Last)

Age

Session

Which Camp, Class, or League?

How much are you able / willing to pay towards participation in these programs?________________________________________ Why are you requesting a scholarship for Kroc Center program(s)? Please list any special circumstances you would like us to know. 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 Program 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


full-program-scholarship-packet-7-2012