Pink Arrow Financial Assistance Form

Pink Arrow IV T-shirt

Financial Assistance Form

Through the generosity of several Lowell families who have made donations, Pink Arrow t-shirts are being made available to students that need financial assistance at a reduced cost.  Youth sizes x-small to adult x-large are $4.

Personal Information

Name of parent/guardian of student to receive assistance__________________________

Address __________________________________________________________________

Phone______________________

Number of adults in the home_________  Number of dependents____________

Are you currently employed?  Yes or No

Employer___________________________________

If you receive state, federal, or county aid, food stamps, medical aid, free or reduced lunch, etc., please circle.

Student Name	School	Grade/Teacher	Size	Cost
1.
2.
3.
4.

                                                                                                Total Amount Due  $____________

The undersigned acknowledge that the information contained in this application is considered confidential and will be made available to employees and officers, agents, or others where it is reasonably necessary to review financial assistance funds.  I certify that the information I have

Provided is accurate and correct to the best of my knowledge.

_______________________________________                  ________________

 Signature of applicant                                                           Date

Please return application and money or check made out to Lowell Area Schools no later than Thursday, September 8, to any Lowell School building principal.