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Wellness Grant Scholarship

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Salem Community Center

Wellness Grant Application

(Formerly known as the Scholarship Application)

 

The Salem Community Center is a private not for profit organization dedicated to the improvement of the quality of life within our community. Grants for individual memberships are available for those individuals who desire to participate but need financial assistance.

GUIDELINES:

  1. Applicants must reside in the Salem Community Center service area.
  2. Financial and medical documentation is REQUIRED for grant consideration.
  3. Financial assistance can be granted for one 4-month membership term, one 8-month membership term or the entire length of an annual membership term based on need and usage.
  4. Financial assistance is not transferable.
  5. Applicants MUST commit to a minimal financial contribution to be considered for a scholarship.

APPLICATION PROCESS:

  1. A complete application must be filled out for individual membership consideration. Any missing information will delay the processing of the application.
  2. The information provided by the applicant will be used only for the purpose of the grant review.
  3. Return the application and additional financial information requested to the Salem Community Center Front Desk. If you have any questions completing the application process, contact Heather Young at (330) 332-5885.
  4. Applications will be reviewed three times a year and should be received by the 10th of the month prior to that session.                    

                                 The deadlines are as follows:

                            Dec 10                  January through April session

                            April 10                  May through August session

                            August 10              Sept. through December session

*Any applications turned in after the 10th of the month will not be considered until the next session.

 

 

 

Salem Community Center

Wellness Grant Application Form

 

 

Name ____________________________________________ Date____________

Parent(s) Name (if applicant is under 18) ________________________________

Address___________________________________________________________

City ______________________________ Zip Code _______________________

Home Phone _______________________________________________________

Date of Birth   ________________    

Marital Status   ________________            

School / Employer ___________________________________________________

A copy of last year’s Federal IRS form (1040, 1040A or 1040EZ) and/or a copy of SSI statement or other disability income must be attached to verify annual income.  

 

Number of Dependents _______________________________________________

 

  • Detail Job History including dates: ____________________________________________________________________________________________________________________
  • Are you claimed as a dependent on someone else’s tax return? Yes ____No ____
  • Describe your financial status during the last 12 months? (additional income than listed, loss in child support,etc. please explain):

      ____________________________________________________________________________________________________________________

What monetary amount are you able to pay? A minimal contribution is required to qualify for a scholarship.      $ per month

  • If receiving SSI, describe the nature of your disability. Add medical documentation, if available.

      _____________________________________________________________________________

      _____________________________________________________________________________

  • List any prior participation in the Salem Community Center or any other Health facility’s activities and programs within the last five years:
  • _____________________________________________ _____________________________________________________________________________

Complete the following with requested information for Household members:

Names of Household Members Age Sex

Relationship

Employer or

School / Grade

Monthly Income

 

1.

         

 

2.

         

 

3.

         

** Monthly income sources include, but are not limited to, earnings, welfare payments, child support, alimony, pensions and Social Security.

Check the type(s) of activities each applicant is interested.

Fitness Activities:                                    

____ Fitness Floor                                   

            ____ Walking Track                                 

            ____ Pool    

            ____ Gymnasium

 

Have you ever applied for a Salem Community Center Wellness Grant? ________ When? _____

 

Note any additional information the Wellness Grant Committee should consider in its decision:

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

 

Submitting this information, I understand that the Salem Community Center expects wellness grant applicants to attend the SCC on a regular basis and have arrangements for transportation prior to the beginning activity.

 

 

Signature: _____________________________________________ Date: __________________________    

                     Parent Signature (if applicant is under 18)