MIDDLETOWN COMMUNITY FOUNDATION
RECREATION FEE ASSISTANCE PROGRAM APPLICATION

Application must be mailed with program registration to:
Middletown Community Foundation, PO Box 1128, Langhorne, PA 19047

Financial aid is provided by private donations from families and businesses in Middletown Township. Fee assistance is granted solely on the family circumstances. All information provided is held in the strictest confidence.
Applicants must:

Be registered for a Middletown Township Recreation Program (including athletic association programs)
Be a Middletown Township resident
Show a need for financial assistance


Please type or print clearly with ink. Complete all sections.

Participant's name ____________________________________________________ Age _____________________

Address ______________________________________________________________________________________

Daytime phone (including area code) __________________________ Evening phone _________________________

Sport registering for: _____________________________________________________________________________

Athletic Association _________________________ Location ____________________ Cost _____________________

Amount family can contribute: _______________ Amount Requested: _________________

_______ # of adults in household ________ # of children in household

Families must list both parents/guardians

Name of Mother/Guardian Name of Father/Guardian
__________________________________ ___________________________________________

Occupation Occupation
__________________________________ ____________________________________________

Annual Income (gross) Annual Income (gross)
__________________________________ ____________________________________________

Other income (such as Soc. Sec, pension, Other income (such as Soc. Sec, pension, AFDC, Child Support)
AFDC,Child Support)
__________________________________ ____________________________________________

Please tell us why you are requesting fee assistance. Be specific. Use the back of this paper if necessary.





Please list a person who knows the family situation who can provide a reference such as a school counselor, social worker, scout leader, religious leader.

Name _____________________________________________ Phone: __________________________________

Relationship to applicant: _______________________________________________________________________

Organization _________________________________________________________________________________