Reformation Evangelical Lutheran Church & School
Reformation Lutheran School
4670 Mt Abernathy Avenue San Diego, CA 92117 Phone: (858) 279-3311
[email protected]
Tuition Assistance Application Form for 2014-2015 School Year (July 1, 2014 – June 30, 2015) Date: _________
1. Applicant I (Parent/Guardian) Last Name: ___________________ First Name: ________________ Middle:___________ Address: _____________________________________________ Apt #: ___________ City: ___________________ State: ________________ Zip Code: ___________ Home Phone: (____)__________________ Cell Phone: (____)________________ Member of Reformation Church? (Yes No) Email Address: _______________________ Member of a Wisconsin Evangelical Lutheran Synod Church? (Yes No) _____________________ 2. Applicant II (Parent/Guardian) Last Name: ___________________ First Name: ________________ Middle:___________ Address: _____________________________________________ Apt #: ___________ City: ___________________ State: ________________ Zip Code: ___________ Home Phone: (____)__________________ Cell Phone: (____)________________ Member of Reformation Church? (Yes No) Email Address: _______________________ Member of a Wisconsin Evangelical Lutheran Synod Church? (Yes No) _____________________ Relationship between Applicant I & II: Married __ Divorced __ Separated __ Other ________ 3. Student #1 Last Name: ___________________ First Name: ________________ Middle:___________ Grade Enrolling: _____________ Years at Reformation School: ___________ Relationship to Applicants:__________________________ 4. Student #2 Last Name: ___________________ First Name: ________________ Middle:___________ Grade Enrolling: _____________ Years at Reformation School: ___________ Relationship to Applicants:__________________________ 5. Student #3 Last Name: ___________________ First Name:________________ Middle:___________ Grade Enrolling: _____________ Years at Reformation School___________ Relationship to Applicants: __________________________ 6. Registration & Tuition Costs (For the 2014-2015 School Year) Monthly Annual Registration Costs N/A _______ Tuition Costs _______ _______ Amount Paid-to-Date for the school year (Registration) Amount Paid-to-Date for the school year (Tuition)
_______ _______
7. Amount of past-due tuition you still owe for the previous school year (If any) $_________ 8. Did you apply for Financial Assistance last year? Y N Was it approved? Y N Note: Financial Assistance is not provided for Registration fees. Tuition Assistance Application Form 2014-2015 Rev 01-2014
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Monthly Income Income – after taxes
Applicant I
Applicant II
Totals
Alimony & Child Support Income
Income Other Total Monthly Income Monthly Expenses Church Offerings/Tithe Housing Utilities – phone, cable, water, SDGE Transportation/gas/insurance Car payments Food/Supplies Entertainment Credit Cards/Loans Medical/Dental Insurance (Other) Childcare (not at Reformation)
+
=
+
=
Alimony & Child Support Expense
Misc. Expenses Total Monthly Expenses Balance = Income - Expenses Tuition Monthly Rate Balance Remaining Own an RV, camper, boat? Y N Own a vacation home/condo? Y N Vehicle(s) Model & Age
Applicants must attach the front page of the most recent federal income tax return and a payroll stub/earnings statement (with SSN crossed out) in order to be eligible for financial assistance. Additional Information for consideration: ____________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ In the understanding that Christian Education is a God-given obligation of parents, and that it is a priority in your life of Christian Service to your children, how much are you able to pay per month? $________________. I agree to pay this amount each month while awaiting a determination on my financial assistance application. I understand that Financial Assistance is contingent on satisfactory student academic progress and classroom behavior. I certify that the above information is accurate to the best of my knowledge. ============================================================================ ____________________________________ Signature of Applicant I (Date) Tuition Assistance Application Form 2014-2015 Rev 01-2014
____________________________________ Signature of Applicant II (Date) 2
9. Administrative Use Only Date Received: ______________ Family Name:______________________________ Financial Responsibility Committee (FRC) Decision: Amount of Financial Assistance Granted (Total): Tuition Assistance: $_________ Other Assistance: $______________ Total Tuition Applicants must pay: $__________ Monthly tuition payment due by applicants: $_____________ Conditions applied to tuition assistance: ________________________________________ Registration payment schedule granted (if applicable): $________/Month Date FRC met with Applicant(s) and/or notified them of decision:______________ (Date) FRC Chairman’s Signature: ___________________/____________ (Date) Copy to: Board of Day School Principal
Tuition Assistance Application Form 2014-2015 Rev 01-2014
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