Rush 2018 Financial Assistance Application

In order to be considered for financial assistance, please complete this form. The Scholarship Committee will review your application at the first scheduled meeting following the receipt of your application and supporting information.

** After May 15, you will be notified via e-mail of the committee’s decision regarding your request, and we will email you registration forms to be filled out and returned in a timely manner.

*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):