Howell PAL

Please fill in each line below by printing clearly.  Incomplete information will not be processed.

       Date: _________________

       Parents / Guardians Name:  _____________________________________________________

       Address:  _____________________________________________________________________

       City: _____________________________________ State ______________ Zip _____________

       Phone: (Home) _ ______________ (Cell) __________________ (Work) ___________________

       Email Address: ________________________________________________________________

       Name of Participant: __________________________________________   Age:  ___________

       Program Name:  _____________________________   Days per Week Attending: __________

Submit completed copy of last year’s Federal and State Income Tax Returns for ALL household members.  Tax returns must include the signatures of the taxpayers, all applicable schedules and copies of W-2 Forms.

Submit copies of the 2 most recent pay stubs showing year-to-date amounts for each parent/guardian.

If applicable, submit copy(s) of all other forms of income including unemployment statement.

If applicable, submit copy(s) of all other forms of assistance including Food Stamps, Free/Discounted Lunch Program and Other Government Assistance.

Provide in writing any other unusual circumstances that Howell P.A.L. should take into consideration when evaluating your School Care Scholarship Request.

I certify that all of the information being submitted is true and correct.  I understand that the Police Athletic League of Howell Township may verify the information submitted.

SIGNATURE (ADULT): ____________________________________________ DATE: ______________

Please note that scholarships are very limited.  Failure to submit all applicable items above will delay the review of your School Care Scholarship Request.