HERSHEY SOCCER CLUB HARDSHIP WAIVER PROGRAM FOR RECREATION & TRAVEL SOCCER

HERSHEY SOCCER CLUB

HARDSHIP WAIVER PROGRAM FOR RECREATION & TRAVEL SOCCER

Hershey Soccer Club (HSC) provides Hardship Waivers to help youth participate in soccer programs in Derry Township.  Specifically, this waiver program provides assistance with fees to youths from low income families or families who have experienced sudden financial hardships. The amount of the scholarship is case-based and is for a single ‘soccer’ year.  Applications must be completed for any year a player wishes to receive assistance.

To be eligible for a HSC hardship waiver, a child must:

• Qualify for free or reduced school lunch or
• Be receiving assistance from one or more of the following programs: General Relief, food stamps, ADC, Foster Care, Medicaid or SSI or
• Child’s family must show that they are experiencing a sudden financial hardship

AND

• Be of age to participate in a HSC soccer program;
• Make a commitment to attend a minimum of 80% of scheduled practices and games and commit to a full ‘soccer year’ (Aug 1- July 31) with a team.

Priority is given to eligible youth meeting one or more of the criteria below:

• Member of a Multi-child family
• Living in a single parent home
• Recommended by a social worker

If your child meets the above guidelines and is eligible for this program, please COPY the HSC Hardship Waiver Application below onto a WORD DOCUMENT, FILL IT OUT and mail to PO Box 66, Hershey PA 17033 or scan and E-MAIL to briggspa5@aol.com.

If you have any questions, feel free to email HSC at briggspa5@aol.com.

                                                                                                                                HERSHEY SOCCER CLUB

                                                                                                  YOUTH SOCCER HARDSHIP WAIVER APPLICATION

Please complete the following information, one application per child:

Child’s Name: _________________________________ Age: _____ Male/Female:_____ Birthdate_____________

Parent/Guardian: ___________________________ Home Phone: _______________

Work Phone     __________________E-mail address__________________________________________

Family Address: _______________________________________________________________________________

Street, City, State, Zip

School Child Attends:______________________________________________

Grade:______________________

Does your child qualify for free or reduced school lunch:             YES     NO

Do you receive assistance from one or more of

the following programs: General Relief, food stamps,

ADC, Foster Care, Medicaid or SSI:                                                  YES     NO

Has your family experienced a sudden financial Hardship:        YES     NO

If yes to sudden financial hardship, please briefly explain: ____________________________________________________________________________________

Has your child ever received a waiver from HSC?                         YES     NO

 CONSENT TO EXCHANGE INFORMATION

I understand that additional information may be required to adequately serve myself/my child, to coordinate services with other agencies, and to verify eligibility for scholarships. By signing this form, I am allowing agencies to exchange certain information so it will be easier for them to provide or coordinate this scholarship. I certify that all of the information I have supplied is true and correct. I permit Hershey Soccer Club volunteers to verify the information on this application. I understand that my child(ren)’s participation in this program requires a commitment to attend a minimum of 80% of the scheduled practices and games and commit to a full ‘soccer’ year (Aug 1- July31)

REQUEST FOR HARDSHIP WAIVER

I am currently enrolled in a public assistance program mentioned above or have experienced a sudden financial hardship in the family. I request a waiver from the Hershey Soccer Club (HSC) and give my permission for HSC to verify the above information:

Parent/Guardian Signature:______________________________________________

____________________________________________  Dated:__________________

(Printed Name of Parent or Guardian)