Financial Assistance Application

DCH understands that people sometimes need support. Our financial assistance policy helps qualifying individuals. We are dedicated to serving everyone, no matter their financial situation. All applications are confidential. We use a sliding fee scale based on income and family size to assess assistance. You will need to pay part of the program fees. You must submit updated information every year you apply. DCH will respond to your request within four weeks after receiving all required materials. Applications with missing information will delay review. If you don't respond within 10 business days, your offer and registration will be canceled.

Parent Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Status

Number of Working Adults in Household

List names (last names also if different from yours) and ages of all persons in the household.

With which programs do you need assistance?

List all household members who will participate in this program.

How much do you feel you can afford to pay?

Have you previously received assistance from DCH?

If yes, which program(s) did you receive assistance?

4. What would you average your monthly household expenses to be?

Please tell us about the circumstances that should be considered in reviewing your application.

I hereby certify that I have read and completed the attached DCH Financial Assistance application indicating the total number of persons in my household and the total gross annual income received during the past twelve (12) months as required to determine eligibility to participate in DCH programming based on low/moderate income designation. I declare that the statements are true and correct to the best of my knowledge. If requested, I will provide further substantiation of all facts, including current income. I agree to inform the DCH of any material change to my financial status and employment. I understand that any assistance I might receive is due to the generosity of others, and I agree that if I submit false information or don’t tell the DCH about changes in my situation, I could lose this assistance. I will keep my end of the financial commitment outlined in my financial aid package. If I am granted a payment plan, I agree to keep those payments up to date. I understand that DCH could end the assistance granted to my family if I do not uphold my financial commitment.