The Charity of Spartan300 Guidelines and Application

- Step 1 of 6

Who is making this request?

Name *

First

Last

Email *

Phone

Requestor's relationship to applicant: *

Self
Spouse
Child
Other

If other... *

Applicant's Name (if other than self): *

First

Last

Is the applicant for benefits a minor? *

Yes
No

How is the applicant affiliated with West Springfield High School? *

Alumus
Student
Teacher
Staff
Other

If other... *

Describe how the financial aid will be used and any impact on the applicant's circumstances. *

Describe the level of support the applicant has from insurance, family, friends and community. *

Do the applicant and requestor give permission and allow the Charity of Spartan 300 to publicize the circumstances as part of our fundraising operation?

Yes
No

Advice Agreement *

I agree

In checking this box, I am agreeing the requestor and/or applicant understand that any advice offered by The Charity of Spartan 300 reflects the opinion of those individuals and is in no way to be considered medical, legal or professionally provided advice. Specific advice should be obtained from a practitioner.

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Information Agreement *

I agree

In checking this box, I am agreeing that all of the information provided in this application is true to the best of my knowledge.

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13103 Mill Rd, Fredericksburg, VA 22407

(918) 824-5724

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