P.O. Box 56 Morton, IL 61550

BLAZE SC

P.O. Box 56 | Morton, IL | 61550

www.blazesc.com | 309-657-5522

Financial Assistance Application

All information contained within this application shall be confidential and shall be used for the sole purpose of determining eligibility for Financial Assistance.

Player/Applicant’s Name: ______

First Last Team:

Birth Date: ______

Street Address: ______

City, State, Zip: ______

Home Phone: ______

With whom does the applicant live? □ Both parents □ Mother □ Father □Other

Parent/Guardian Name(s): ______

Cell or Work Phone: ______

Email address: ______

Occupation: ______

Annual Family Income: (Include gross wages, public assistance, child support/alimony, social security, disability, other):

$ ______

(We may require copies of a recent tax return to verify)

Number of family members in home (include parents and children): ______

Family’s Contribution to Fees: $ ______

Financial Assistance Amount Requested: $ ______

Do you plan to participate in the Blaze SC Fundraiser offered to you as a way to offset your players fees?

Yes ______No ______

Please list any special circumstances that contribute toward your need for financial assistance:

______

______

______

______

______

______

Continued on page 2 – Incomplete applications will not be considered

Financial Assistance is granted on a seasonal basis and a new application must be submitted each season. Financial Assistance will be granted prior to the start of the season. Late applications will be evaluated and will be granted based on remaining available funds.

Any player awarded Financial Assistance for a season will be required:

1 - To participate in the seasonal club fundraiser and raise at least 50% of projected fee.

2 - Work 4 additional hours at the Blaze SC home tournament, in addition to the already required 4

hours. 8 total hours. If there is no tournament, we may call upon you to help in other ways, such as helping at tryouts, helping at Fee Night, etc.

The Blaze SC Board of Directors reserves the right to request any additional information relating to this application including but not limited to prior years tax returns, W-2’s, and any other documents that assist with the assessment of financial need. This application is strictly confidential.

By signing and submitting this application, I as the applicant’s parent/guardian agree to ensure that the applicant participate in team practices, games, and team duties as well as any other regular team activities. I understand that non-participation in these activities could result in termination of my Financial Assistance.

I certify that all materials supplied and statements made in connection with this application are true to the best of my knowledge.

Parent/Guardian Signature: ______Date: ______

Please send completed applications to:

Blaze SC

P.O. Box 56

Morton, Illinois 61550

* DEADLINE FOR CONSIDERATION:______MARCH 1, 2016______

They can also be scanned and emailed to:

Blaze SC Use only:

Date Received ______

FA Granted: □ Yes □ No

FA Amount: ______

Date of Letter to Applicant: ______

Notification to Team’s Head Coach ______

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