Discount Application

indicates a required answer

Please fill out this form and return for consideration for a discount. This information will be kept strictly confidential.

1. *	Date:

2. *	Client(s):

3. *	Responsible Party:

4. *	Address:

5. *	Phone Number:

6. *	Email:

7. *	Place(s) of Employment:

8. *	Number of dependents, including yourself:

Please check the following that applies to your chiild(ren):

Learning disability		Developmental delay
Diagnosis by a school or medical professional		Has an IEP (Individualized Education Plan)
Physical disability		Utilizes an assistive device (wheelchair, AAC, etc.)
Other

10.	If you have checked any of the above in #9, please write a short explaination:

11. *	Medicaid (yes/no):

12.	Copy of Medicaid card:
	Allowed extensions: csv, doc, docx, dot, gif, heic, heif, htm, html, jpeg, jpg, m4a, mov, mp3, mp4, pdf, png, pps, ppt, pptx, pub, rtf, svg, txt, xls, xlsx, yyz, zip

Please include the following income verification as appropriate:

13.	Gross Family Monthly Income:

14.	Gross Family Yearly Income:

15.	Pay Stub 1:
	Allowed extensions: csv, doc, docx, dot, gif, heic, heif, htm, html, jpeg, jpg, m4a, mov, mp3, mp4, pdf, png, pps, ppt, pptx, pub, rtf, svg, txt, xls, xlsx, yyz, zip

16.	Pay Stub 2:
	Allowed extensions: csv, doc, docx, dot, gif, heic, heif, htm, html, jpeg, jpg, m4a, mov, mp3, mp4, pdf, png, pps, ppt, pptx, pub, rtf, svg, txt, xls, xlsx, yyz, zip

17.	Federal Tax Return (1040 form):
	Allowed extensions: csv, doc, docx, dot, gif, heic, heif, htm, html, jpeg, jpg, m4a, mov, mp3, mp4, pdf, png, pps, ppt, pptx, pub, rtf, svg, txt, xls, xlsx, yyz, zip

18.	If you do not wish to submit financial documents, please explain your current financial situation:

I certify the above information is accurate. If it is discovered to be in error, I understand I may lose the option of any scholarship.

19. *	Signature:
	By typing my name below, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature.