Application – West Lincoln Community Care

Step Up- West Lincoln Community Care Grant Application Form

Date of application:

CHILD/TEEN INFORMATION:

Name:

Birthdate:

Age:

Has this child applicant rec'd a Step Up Grant from WLCC: Yes No

When:

PARENT/GUARDIAN INFORMATION:

Name:

Relationship to child:

Address:

Home Phone:

Cell#:

Email:

Approved to Office Use Only:

Applicant MUST submit a copy of the sport/cultural registration form, fees and contact information to support your application.

Organization Name:

Phone:

Type of Activity:

Contact:

Registration Fee:

Total amount of Grant Requested:

Approved:

CLIENT FINANCIAL INFORMATION:

You must attach a copy of the personal income assessment including all adults over 18 living in the home.

I have completely read and understand all the application instructions and certify that all theinformation provided including attachments are correct and can be independently verified. I authorize WLCC to contact the Organization that I have listed above if any further information or verification is required.

Date: