Sliding Scale Application

Northwind Riding Academy Sliding Scale Application

First name

Last name

Phone

Birthday for responsible party

Month

Day

Year

Rider name(s) if different from above.

Multi-line address

Country/Region

Address

City

Zip / Postal code

Sliding Scale Tuition Homeschool Class

Sliding Scale Tuition Lesson Package

Program Applying for

Lessons Program (4 lessons – $275 baseline)

Homeschool Course (4 lessons – $400 baseline)

Total Gross Household Income

Number of adults living in household

Number of children living in household

Do you currently receive financial assistance (e.g., SNAP, WIC, unemployment, etc.)?

Yes

Requested tear level (Optional)

Brief explanation of why you are requesting sliding scale assistance.

Why do you want to participate in our program? (Briefly explain your motivation and what you hope to gain)

Attach one of the following to your application: Previous year's tax return or a paycheck stub dated within the last 30 days

I certify that the information I have provided is true and accurate to the best of my knowledge. I understand that NorthWind Riding Academy may verify this information. The agreement will be reviewed annually or with a significant change of circumstances.

Signature

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Date