The Hope Fund Individual Application

Child's Age

Applicant (Child's Name)

Child's Physical Address (Street, City, State, Zip)

Parent or Guardian Name

Phone Number of Parent or Guardian

Email of Parent or Guardian

Name of person submitting this application

Relationship to applicant/child

Total Household Annual Income (MUST INCLUDE ALL household members)

Upload your last pay stub with Year to Date (YTD), latest Social Security benefits letter and/or most recent W-2 *

E-mail

Phone

Mailing address of person completing this application (Street or PO Box, City, State, Zip) if different than parent or guardian

Please describe what you are applying for

Please describe why support through the Hope Fund is needed

Total Cost of activity/item

Dollar amount requested from United Way for activity/item

Please describe how Hope Fund support will make a difference in the child's life

What other resources for this request have you received or requested?

If approved for funding, United Way will only make payments directly to the vendor (i.e. school, gymnastics, specific camp, music store, etc.). Applications will be considered incomplete without this information.

Vendor

Vendor address (Street or PO Box, City, State, Zip)

Vendor Phone

Contact Person (if known)

By checking this box I give permission for information contained in this application to be shared with the United Way of the Tri-Valley Area Hope Fund Review Committee. It will be treated confidentially and with respect. Yes

By checking this box I will not hold United Way liable for any funding decisions that are made, or for the applicant's participation in an activity, or for use of any material provided with The Hope Fund funding. Yes

Start date of activity

The Hope Fund Individual Application

Payment Information

Consent and Waiver of Liability