Financial assistance from the LJCC Complete the form below to request a reduction in fees Scholarship Application Your name(Required) First Last Your date of birth(Required) MM slash DD slash YYYY Your address Street Address Address Line 2 City ZIP / Postal Code Your phoneYour email(Required) I/We are applying for financial assistance to help cover the costs of:(Required)Check all boxes that apply Individual membership Single-parent family membership Two-adults membership Family membership Cohn Early Childhood Learning Center Camp Youth athletics (for example youth soccer, basketball, tennis lessons, etc.) Aquatics (for example swimming lessons, dive team, etc.) Other If you chose "other" in the previous question, please specifyHow much would you be able to pay the LJCC each month?(Required)Membership number (if known)Employment status(Required) Employed Not currently employed Employer(Required)Occupation or job title(Required)Name of supervisor plus phone number(Required)Do you want to list a spouse or partner?(Required)A second adult included on your membership must reside at the same address. Yes No Spouse/Partner's name(Required) First Last Spouse/Partner's employment status(Required) Employed Not currently employed Spouse/Partner's employer(Required)Spouse/Partner's occupation or job title(Required)Spouse/Partner's supervisor plus phone number(Required)Do you want to list any dependent children?(Required)Dependents (up to age 26) must reside at the same address as the membership holder. Yes No List your dependent children's names and birthdates Add RemoveYour financesYour income from last year (wages, tips, etc.):(Required)Spouse/Partner's income from last year (wages, tips, etc.):Child support you received last year:Child support your spouse received last year:Social Security payments you received last year:Social Security payments your spouse or partner received last year:Unearned income (pensions, dividends, etc.) you received last year:Unearned income (pensions, dividends, etc.) your spouse or partner received last year:List any income you received from other sources (rent, support from relatives, etc.):List any income your spouse or partner received from other sources (rent, support from relatives, etc.):Spouse/Partner's total income last year:(Required)Your total income last year:(Required)Your estimated total income for this year:(Required)Spouse/Partner's estimated total income for this year:Are you receiving financial assistance from any government or local agency?(Required) Yes No List assisting agencies here(Required)Do you currently have any outstanding LJCC dues?(Required) Yes No Not sure Describe any extraordinary expenses or special circumstances that you are dealing with. Be specific regarding cost and duration.Additional documentationIn addition to completing this online form, we will also require you to provide the following documents to the LJCC as part of your scholarship application:(Required)We will process your application when we receive the following pertinent documents from you (either delivered/mailed to the LJCC, emailed to hr@bhamjcc.org, or attached to this form below). Please check the box for each document you will provide. (Required) Copy of your two most recent IRS 1040 forms or a note that you do not have to file income tax (Required) Your two most recent pay stubs A disability letter (if you are receiving disability) A Social Security award letter (if you are receiving Social Security) An unemployment statement (if you are receiving unemployment) Attach relevant documents here.Max. file size: 10 MB.Max. file size: 10 MB.Max. file size: 10 MB.Max. file size: 10 MB.Max. file size: 10 MB.CAPTCHAPhoneThis field is for validation purposes and should be left unchanged. Δ
