BRADDOCK ROAD YOUTH CLUB

							                                    BRADDOCK ROAD YOUTH CLUB
                                      RECREATIONAL SOCCER
                               APPLICATION FOR FINANCIAL ASSISTANCE




The Braddock Road Youth Club Recreational Soccer program encourages players to participate in the sport.
Through the availability of donations received, BRYC is prepared to help players with financial assistance for
registration and uniform fees. This assistance is available for those who qualify, based on need. All applicants are
encouraged to pay a portion of the registration fee (a minimum of $25.00 per player to cover fixed operating costs),
according to their financial ability.

Please complete this application and forward it to: BRYC Recreational Soccer, PO Box 2084, Fairfax, VA
22031. The information contained on this form is considered private and will be handled in an administratively
confidential manner. Your registration for the soccer season is not complete until this form is returned.

Name of Player: _______________________________________                    Date of Birth: ___________________
Name of Parent/guardian: _______________________________                   Home Phone: ___________________
Address: _____________________________________________                     Work Phone: ___________________
           _____________________________________________
School Player Attends: __________________________________                  Grade: _________________________
# in Family: _____________ # of Wage Earners: ____________
Financial Assistance Provided in Previous Season? YES / NO
Requesting Financial Assistance For:     _____ Registration          _____ Uniform


This family qualifies for some amount of assistance because we have been approved for:
_____ Public Assistance                  _____ Medical Assistance                  _____ Unemployment
_____ Food Stamps                        _____ Free/reduced school lunch           _____ Energy Assistance
_____ Section 8 or Public Housing                   _____ Other Special Consideration (please explain)
Remarks:_____________________________________________________________________________________
_____________________________________________________________________________________________

In return for receiving financial assistance, BRYC encourages you to participate in club and team activities, which
may include assisting with registration, field maintenance, coaching, team parent, or other volunteer positions.

BRYC considers your application for financial assistance to be a serious and legal matter. By signing this form, you
certify that the information provided is correct and give BRYC written permission to verify the information.

Signature of Parent/Guardian: ______________________________________ Date: ________________


Administrative Use Only:       League: __________
Check # __________             Registration fee rec'd __________     Uniform fee rec'd __________ Late fee rec'd __________
BRYC Assistance Provided:      Registration fee ______________       Uniform fee _______________ Late fee ______________




     Rev 9/02