Request for Financial Assistance
Eshel National Retreat 2016
Timeline for applying for financial aid:
1. Send in Financial Aid form below by December 1st for priority consideration.
2. Financial Aid awards will be sent within two weeks. If you apply after the priority deadline, chances of receiving aid may go down.
3. You will receive instructions and a registration code and have three days to register. After that time the aid will be passed on to someone else.
- Personal Information
Primary Applicant’s (adult) Name ________________________________________
Home Phone: ______________________ Cell Phone: ___________________
Work Phone: ______________
Email Address: ______________________________________________
Number of dependent children: _____
In 2-4 sentences please tell us why you would you like to attend the Shabbaton.
Why are you requesting aid? If you are a student, tell us about your school and what you are studying:
How much aid are you requesting?
Is this your first Eshel event? If not, which one(s) have you attended?
Would you be willing to volunteer or are you already volunteering at the retreat?
We need help with childcare, can you assist those doing children’s programming?
II. Income Source Annual/Weekly/Monthly (circle one)
- Gross salary – Applicant $ ____________
Gross salary – Spouse/Partner $ ____________
- Non-Salary Business Income (include rental income and tips) $ ____________
- Child Support/Alimony $ ____________
- Unemployment Compensation $ ____________
- Other, Please Specify (parents, other relatives, etc.) $ ____________
Total Annual Income: $ ____________
III. Recurring Expenses (please estimate) Annual/Weekly/Monthly (circle one)
- Rent/Mortgage $ ____________
- Utilities (include: Gas and electric, phone, cable, cell phone) $ ____________
- Insurance (car, home, life and health) $ ____________
- Auto Payment $ ____________
- School tuition $ ____________
- Groceries $ ____________
- Leisure and Entertainment (movies, theater, travel etc.) $ ____________
- Other (e.g., medical bills, loans, special needs, tutors) $ ____________
Total Annual Expenses: $ ___________
- Other (Describe any extraordinary expenses or special circumstances (e.g. unemployment, savings or financial support you receive.)
I understand that any scholarship offer must be kept confidential, and I agree to do so. I hereby affirm that the information shown on this form is accurate. I understand that should any information change regarding my financial circumstances I will inform Eshel staff in writing.
Applicant’s signature:____________________________________ Date:______________________