Special Considerations Application 2021-2022

Special Consideration Funds will be distributed on a first-come-first-serve basis. Once our Special consideration funds have been exhausted, we will no longer be able to accommodate any requests.

All information provided and all communication will be strictly confidential to protect both the family and the integrity of the Special Considerations process. We, who are entrusted with the responsibility of according financial assistance, will do so in a fair, equitable and transparent manner.

Please read the following stipulations prior to filling out the form. By "submitting" the form, you have agreed:

Special Financial Consideration applies to member dues, debt service fund, and Jewish Learning Center (JLC) Tuition. No reduction can be considered for Early Childhood Center, Sabra/Hebrew for Credit, textbooks and supplies fees, Bar/Bat Mitzvah Tutor fees.
All forms must be filled out COMPLETELY, and signed by all applicant individually in order for your application to be processed.
Invoices and monthly statements showing amounts due and due dates will be mailed or emailed to you.

* I have read the above stipulations and do hereby agree.

I have read the above stipulations and do hereby agree.

* Name:

* Today's Date

PRIMARY MEMBER INFORMATION

* First Name

* Last Name

* Marital Status

* Email

* Mobile

* Birth Date

Age:

* Occupation

* Employer

* How many years have you been employed by this company?

SECONDARY MEMBER INFORMATION

First Name

Last Name

Mobile

Birth Date

Age:

Occupation

Employer

How many years have you been employed by this company?

FAMILY INFORMATION

* Address

* City

* State

Home Phone

Leave blank if there is no home phone

DEPENDENT INFORMATION

Please list all of your children and/or your parents that are living in your home.

Dependent #1 Name:

Birth Date

Age:

Relationship:

Dependent #2 Name:

Birth Date

Age:

Relationship:

Dependent #3 Name:

Birth Date

Age:

Relationship:

Dependent #4 Name:

Birth Date

Age:

Relationship:

Dependent #5 Name:

Birth Date

Age:

Relationship:

ANNUAL INCOME & EXPENDITURES

* TOTAL INCOME:

* TOTAL EXPENDITURES:

* NET SURPLUS (DEFICIT)

* I certify all information is true and correct to the best of my knowledge.

I certify all information is true and correct to the best of my knowledge.

* Name of Primary Applicant

Today's Date

* Please state your reasons for requesting Special Considerations.

Upload a File

You may attach any other documentation that you feel to be relevant.

SPECIAL FINANCIAL CONSIDERATION REQUEST

Section I.

Membership Category + Annual Dues

Family ($3,575): $2,875 plus $500 Debt Service Fund & $200 Security
Family ECC ($2,100): $2,100 plus $500 Debt Service Fund & $200 Security
Enduring Individual ($1,575): $875 plus $500 Debt Service Fund & $200 Security
Enduring Couple ($2,200): $1,500 plus $500 Debt Service Fund & $200 Security
Enduring Family ($2,500): $1,800 plus $500 Debt Service Fund & $200 Security
Single Parent/Individual ($2,210): $1,510 plus $500 Debt Service Fund & $200 Security
Nitzan (NextGen) Individual ($560): $360, plus $200 Security
Nitzan (NextGen) Couple ($925): $725, plus $200 Security
Associate ($1,915): $1,715 proof of membership required, plus $200 Security

If you are applying for special considerations for membership, please choose from the drop-down menu which category you fall under:

* Membership Category (A)

Consideration Requested for Membership Dues (B)

Insert the amount you are asking to be deducted from the total amount of your membership fee.

Total amount Requesting to pay for Membership (C)

(A) - (B) = (C)

Example:
(A) Choosing Family Membership Category = $3,575
(B) Requesting - $500 off of total membership dues
(C) Write in the box above: $3,257

Section II.

Jewish Learning Center Fees

Kindergarten + 1st Grade ($1,113): Textbooks, supplies and safety kits are inclusive
2nd - 6th Grade ($1,718): Textbooks, supplies and safety kits are inclusive

Additional Costs (per child):

$18 Teaching Team Gift

If you are applying for Special Considerations for the Jewish Learning Center program, please indicate below how many children will be attending each program.

Number of Children attending JLC (A)

Kindergarten + 1st Grade ($1,095 per child)

2nd - 6th Grade ($1,700 per child)

Consideration Requested for JLC Tuition (B)

Insert the amount you are asking to be deducted from the total amount of your JLC tuition.

Total amount requesting to pay for JLC tuition (C)

(A) - (B) = (C)
Example:
(A) 1 Child in 1st Grade + 1 Child in 3rd Grade = $2,831
(B) Requesting - $1000 off of total tuition
(C) Write in the box above: $1,831

Section III.

Add Section I & Section II together to get the GRAND TOTAL.
Please add to TOTAL cost you will be paying for below.

* TOTAL AMOUNT DUE AFTER CONSIDERATION

* Subject to approval of your request. Please note that we have a certain amount of funds allocated to Special Considerations, please take that into consideration when you are requesting financial help. The funds will be distributed on a first-come-first-serve basis. Once the funds have been exhausted, we will no longer be able to accommodate any more requests. Thank you.

Sun, June 26 2022 27 Sivan 5782