Patty’s Players Assistance Application

Parent/Guardian Name

First

Last

Relationship to Child

Address

Phone Number

Child's Name

Child's Age & Date of Birth

School Attending

Grade Level

Name of Activity

Organization/Club Name

Contact Person for Activity & Phone Number

Cost of Participation $

Assistance Amount Requested $

Activity Start Date

Activity End Date

to Address Phone

Total House Income $

Number of People in Household

If you receive government assistance, please list here (SNAP, TANF, Medicaid, etc.)

Please describe your financial need and how this assistance will help your child participate in the activity

Signature to Agreement: I certify that the information provided in this application is true and complete. I understand that submission of this application does not guarantee financial assistance and that assistance is subject to availability of funds. If approved, I agree to use the funds solely for the intended extracurricular activity.