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Financial Assistance Form for AKOMA Foundation, Inc., d/b/a Danbury LEGO Robotics, Danbury Robotics Programs
Financial Assistance
PLEASE NOTE: Concerning Financial Assistance Form - All information is kept strictly confidential and has been requested for the sole purpose of establishing financial needs and/or acquiring funds to help support programs or sponsor team members in need.
PLEASE NOTE: One Form should be filled out for whole family, please add any additional team members in this one financial assistance application. See below.
Perspective Team Member First Name
Your answer
Perspective Team Member Last Name
Your answer
Form should be filled out for whole family, please add any additional team members in this one financial assistance application- Please add additional sibling team members names here. If none, please type none.
Your answer
Parent/Guardian No. 1 Primary contact First Name
Your answer
Parent/Guardian No. 1 Primary contact Last Name
Your answer
Parent/Guardian No. 1 Primary contact email address
Your answer
Parent/Guardian No. 1 Primary contact mobile number
Your answer
Parent/Guardian No. 1 Primary contact home number (if none, type none)
Your answer
After completing the Danbury Robotics Application form(s), how much did it total up that you owed for the program(s) (Please state total amount due an owing for all perspective team members for all programs).
Your answer
What percentage of financial assistance are you requesting?
If you checked Other, please explain (if not, type n/a)
Your answer
Does your family receive public benefits from the Department of Social Services or any other similar state or federal agency?
If so which form(s) of assistance do you receive? Please select as many as apply.
If you selected OTHER, please explain. (if not type n/a)
Your answer
If you selected NONE, you may still be eligible due to your family size and income. What is the number of people in your household and annual household wages and income.
Your answer
Please briefly describe your circumstances which would qualify your child to receive financial assistance. if you don't receive government assistance. If you do receive government assistance then you may type "receive government assistance"
Your answer
If we are unable to provide you with financial assistance, will your child (children) be able to participate if we put you on a payment plan?
If yes how much can you pay? (if you put no above type n/a)
Your answer
If yes, how often can you make the payment? (If you answered no above, check none below)
If you can make payments, how will you make payments if you typed none, check non-applicable
By Submitting this Financial Assistance Form, you certify that all the information contained within it is true to the best of your knowledge. If it is discovered that false information was given on this application, then the team member can be terminated immediately from the current program year and any future programs run or supported by AKOMA Foundation, Inc. d/b/a Danbury LEGO Robotics, Danbury Robotics, et.al. Please check that you Understand and agree.
Please make sure you submitted your $10 non-refundable application fee per application, along with the completed Robotics Application per child by July 1. Your financial assistance application will not be considered if the Robotics application is not completed along with payment by the deadline of July 1. Please check that you understand and agree.
Please make sure you submitted this financial assistance form by July 1, otherwise, it will not be considered and your request will be denied. Please check that you understand and agree.
If you have submitted a completed application, You will receive notice by July 5th of the status of your application and your financial aid application. Please check that you Understand and agree.
How did you make the non-refundable $10 application fee payment per application?
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