EmailMe Form - Finanacial Assistance for Registration and Dues

Registration and Dues *

New Member

Renewal

Member Name *

First Last

Member Phone *

### - ### - ####

Email *

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Chapter Request (if any)

Member High School Graduation Year *

Parent Name *

First Last

Number of Adults 18+ Living in Household Full-time *

Number of Children Under 17 Living in Household Full-time *

Why are you applying for financial assistance? *

Total Annual Income for All Sources *

Job Title for Each Person Living in the Household *

Are there other factors we should consider? *

Are you able to pay a portion? if so, how much? *

Do you qualify for (check all that apply):

Supplemental Nutrition Assistance Program (SNAP)

Temporary Assistance for Needy Families (TANF)

Head Start Program

Free or Reduced Lunch Program

Why do you want your teen to serve the community through Lion's Heart? *