Rush 2018 Financial Assistance Application

In order to be considered for financial assistance, please complete this form. 

** Servant Team will be notified via email of the committee's decision regarding your request after February 15.  Regular Attendees will be notified via email after May 15.  

*Address Line 1
Address Line 2
*City
*State/Province/Region
*Zip/Postal Code

EVENT INFORMATION
*For which event are you requesting assistance?:
*Event Date:

1. CHILD INFORMATION
List all children currently living in your household.
Child 1: Full Name & Date of Birth:
Child 2: Full Name & Date of Birth:
Child 3: Full Name & Date of Birth:
Child 4: Full Name & Date of Birth:
*Which child(ren) will attend the event?:

2. PERSONAL USE MONTHLY INCOME
If this application is for a child who is the legal responsibility of a welfare agency or court, list the amount of the child’s personal use monthly income.
Child's Personal Use Monthly Income ($):

3. ADULT MONTHLY INCOME
List all adults currently living in your household. List total gross monthly income before taxes and deductions for each.
Adult 1: Full Name:
Adult 1: Employer:
Adult 1: Monthly earnings from work before deductions ($):
Adult 1: Monthly welfare payments, child support/alimony ($):
Adult 1: Monthly pay from pensions, retirement, social security ($):
Adult 1: Any other monthly income ($):
Adult 2: Full Name:
Adult 2: Employer:
Adult 2: Monthly earnings from work before deductions ($):
Adult 2: Monthly welfare payments, child support/alimony ($):
Adult 2: Monthly pay from pensions, retirement, social security ($):
Adult 2: Any other monthly income ($):
Other Adults: List names, employers, and monthly income.:

4. ADDITIONAL INFORMATION
*Applicant Marital Status:
Additional information you would like to provide to help the committee understand your need (optional):