Financial Aid form for Culture of Safety ProgrammingThis form is for anyone who needs financial support for karate classes or other programs at Culture of Safety/Jin Sei Ryu Karate. We ask all folks who need to pay less than our Reduced Rates to please fill out this form so we can know how to best support you. The first section is about who you are and who in your household or family wants to participate in karate classes or other programming with us.Please enable JavaScript in your browser to complete this form. - Step 1 of 2Your Name *FirstLastYour Email Address *You'll receive a copy of your information via emailPhone *What program are you requesting financial aid for? *KarateDay Camp(s) (No-School Day Camp, Spring Break Day Camp, Summer Day Camp)Empowerment & Self-Defense Program(s)OtherMultiple programsAdditional information If you chose "other" or "Multiple programs," list the program or programsName(s) and age(s) of participants (or potential participants) in your household: *How much can you afford to pay? *Please be specific. If inquiring about karate or another ongoing program, list the amount you can afford per month per person. If inquiring about a workshop or camp, list the total amount you could pay for the camp or workshop per person. NextFinancial InformationThis section gives us information about your specific financial situationHow many people are in your household? *1 - only yourself23456 or moreInclude children, partners, and parents/older generation -- everyone who lives together and pools financial resources).How many people in your household are adult income earners? *123 or moreWhat is your household's combined NET income (after taxes)? *How much money PER MONTH do you have to live on?Do you have any other sources of income? Family support (not from your household)Stocks, Bonds, SavingsUnreported incomeOtherNonePlease describe any additional monetary support or income you receive annuallyHow much do you pay monthly in rent/mortgage? *How much do you pay monthly in medical expenses? *Include health insurance, medications, medical visists, mental health visits, vitamins, and visits with other health/wellness specialists. An estimate is fine.How much do pay monthly for personal debt? *Include personal credit cards, student loans, medical debtDo you financially support people who don't live with you?If you send money to others regularly, note the amount and the frequency (for example, $100/month)Any other major recurring expenses? *For example, car payments, auto insurance. List expense & amountOther extenuating circumstances we should know about?For example, insecure housing, unemployed or underemployed, recent loss of job, financially supporting older folks or folks with disability, recent immigration, immigration status, recent divorce, major medial illness. We will not voluntarily disclose information supplied to us but can not guarantee the security of information submitted via online form.Submit
