Income Based Membership Application Information & Guidelines ed. 7/12
The Salvation Army Kroc Center is pleased to provide access to our facility and our programs. It was Joan Kroc’s vision and expectation that all individuals have equal opportunities to develop and discover their natural gifts and talents. The Kroc Center is a world-class facility designed to do just that! We are delighted that you are interested in participating in our programs. Please read carefully and follow these step-by-step instructions to complete your Income Based Membership application. 1. This packet includes the Income Based Membership Information Form, Agreement Form, and Application Form. 2. Please read the Income Based Membership Agreement Form, sign and date at the bottom of the page. 3. Completely fill out the Income Based Membership Application Form, sign and date at the end. 4. Attach copies of all income verification to the application. Household income means the gross income of anyone who earns and/or receives income and lives in the household. Acceptable forms of proof are dated within the last 30 days: 2 pay stubs, unemployment or worker’s compensation income, TANF/FI, SNAP/Food Stamps, child support or alimony. VA benefits may be dated within the last 90 days. Social Security retirement, disability or SSI may be dated within the last year. For self-employment please provide the first two pages of your last Federal tax return. All household members 18 or older must provide proof of income, proof of unemployment (from Department of Labor) or proof of full time student status (school schedule). 5. Mail the completed information, which includes the Income Based Membership Agreement Form, the Income Based Membership Application, and copies of proof of income to: Kroc Center Attn: Income Based Membership 1833 Broad Street Augusta, GA 30904 Or, you may seal the documents in an envelope marked “Income Based Membership” and drop them off at the Kroc Center Welcome Desk. 6. Incomplete applications (including those missing proof of income) will not be processed. Only complete applications can be considered for an Income Based Membership. 7. Staff members may contact you with questions; please give accurate and neatly written phone and email contact information. 8. You will be notified about the final status of your Income Based Membership application by mail. If approved you must bring your letter and a government-issued photo ID to the Kroc Center to complete membership registration within 30 days of the date on the letter. You will be asked to provide a portion of the non-refundable Registration Fee based on financial eligibility. 9. You may make your membership payments one month at a time, three months at a time, or as an automatic monthly withdrawal from your checking, savings, or credit card account. When you come in to complete your membership registration, you must be prepared to pay your first installment. Should your payments not be received on schedule, we reserve the right to terminate the membership. 10. When you come in to sign up, the customer service representative will complete your membership information on the kiosk, accept your payment, and issue you a membership card.
The Salvation Army Ray & Joan Kroc Corps Community Center - P.O. Box 921 - Augusta, GA 30903 - Phone 706.364.KROC (5762) - www.krocaugusta.org
Please keep this sheet for your reference — Sign and return the other copy of the Income Based Membership Agreement ed. 7/12
The Salvation Army Kroc Center is pleased to provide financial aid for access to our facility and our programs. It was Joan Kroc’s vision and expectation that all individuals have opportunities to develop and discover their natural gifts and talents. The Kroc Center is a world-class facility designed to do just that! We are delighted that you are interested in participating in our programs. Please read carefully. Signing this form means you agree to all the listed requirements. If you have any questions please contact the Member Services department at 706-364-5762 for more information. 1. All Kroc Center Income Based membership and scholarship applications are confidential. You agree to not discuss your application, award, or rates with others. 2. Completing an application does not guarantee you will receive assistance. Income Based memberships are awarded based on income eligibility, funding, timeliness, and space available. Management reserves the right to put you on a waiting list or deny your application if slots are not available. 3. Depending on your household income and size you may be offered a membership rate of 75% or 50% of the regular standard monthly membership rate for your household. You will be asked to pay a portion of the non-refundable Registration fee. This membership allows entry into the facility; access to the aquatics center, fitness classes, and equipment; and participation in open activity times. Members also receive priority access and special member pricing for programs and events. An Income Based membership does not give access to Kroc Center programs requiring tuition. 4. All requests will receive a response by mail. If approved you must return to the Kroc Center to complete membership registration in person within 30 days of the award letter date. 5. You must report and provide proof of all household income. Failure to list income is considered fraud. 6. Please also provide general household expense information but do not attach copies of your bills. 7. Any information found to be incomplete, fraudulent, or false will result in this application and any Income Based memberships issued from it being cancelled. Additional penalties related to participation at the Kroc Center may be given at the discretion of management. 8. You agree to check in and use the recreation facilities at the Kroc Center a minimum of 3 times per month. Should you fail to meet this requirement, we reserve the right to terminate your income based membership. 9. Income Based memberships are valid for 6 months from the date of registration. You must reapply 30 days prior to your membership expiration date to be reconsidered for the next 6 months. 10.The Salvation Army Kroc Center reserves the right to modify the Income Based membership program and guidelines at any time.
Income Based Membership Agreement ed. 7/12
The Salvation Army Kroc Center is pleased to provide financial aid for access to our facility and our programs. It was Joan Kroc’s vision and expectation that all individuals have opportunities to develop and discover their natural gifts and talents. The Kroc Center is a world-class facility designed to do just that! We are delighted that you are interested in participating in our programs. Please read carefully. Signing this form means you agree to all the listed requirements. If you have any questions please contact the Member Services department at 706-364-5762 for more information. 1. All Kroc Center Income Based membership and scholarship applications are confidential. You agree to not discuss your application, award, or rates with others. 2. Completing an application does not guarantee you will receive assistance. Income Based memberships are awarded based on income eligibility, funding, timeliness, and space available. Management reserves the right to put you on a waiting list or deny your application if slots are not available. 3. Depending on your household income and size you may be offered a membership rate of 75% or 50% of the regular standard monthly membership rate for your household. You will be asked to pay a portion of the non-refundable Registration fee. This membership allows entry into the facility; access to the aquatics center, fitness classes, and equipment; and participation in open activity times. Members also receive priority access and special member pricing for programs and events. An Income Based membership does not give access to Kroc Center programs requiring tuition. 4. All requests will receive a response by mail. If approved you must return to the Kroc Center to complete membership registration in person within 30 days of the award letter date. 5. You must report and provide proof of all household income. Failure to list income is considered fraud. 6. Please also provide general household expense information but do not attach copies of your bills. 7. Any information found to be incomplete, fraudulent, or false will result in this application and any Income Based memberships issued from it being cancelled. Additional penalties related to participation at the Kroc Center may be given at the discretion of management. 8. You agree to check in and use the recreation facilities at the Kroc Center a minimum of 3 times per month. Should you fail to meet this requirement, we reserve the right to terminate your income based membership. 9. Income Based memberships are valid for 6 months from the date of registration. You must reapply 30 days prior to your membership expiration date to be reconsidered for the next 6 months. 10.The Salvation Army Kroc Center reserves the right to modify the Income Based membership program and guidelines at any time. By signing below you agree that you understand and accept the Kroc Center Income Based Membership Guidelines. Signature: ____________________________________________ Date: ___________________________ Print Name:____________________________________________
Optional information: How did you hear about the Kroc Center income based membership? _______________________________________________ _______________________________________________________________________________________________________ (For statistical purposes only ) How many members of your household consider themselves: ETHNICITY Hispanic _____ Non-Hispanic _____ RACE Asian _____ American Indian or Alaskan _____ Black or African American _____ White _____
Pacific Islander _____ Multi-Racial _____ Other _____
The Salvation Army Ray & Joan Kroc Corps Community Center - P.O. Box 921 - Augusta, GA 30903 - Phone 706.364.KROC (5762) - www.krocaugusta.org
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CONFIDENTIAL
Kroc Center Income Based Membership Application SECTION I – APPLICANT INFORMATION (Head of Household) ed. 7/12 Date stamp Are you currently a Kroc Center member? __No __ Yes (if yes, mark type below) __ Standard __ Gold __Income-Based __ Scholarship Name (First, MI, Last): _____________________________________________________________________________________ Mailing Address: _____________________________________________City: ______________ State: _____ Zip: ___________ Main Phone: ______________________________ Alternate Phone(s): ______________________________________________ Email: _________________________________________________________________ Birthdate: _______________________ Household Status (choose one): __ Single __ Married __ Widowed __ Divorced __ Significant Other __ Roommate SECTION II – OTHER HOUSEHOLD MEMBERS List all people living in household with applicant. Please indicate if children are foster children. More space available on back. Name (First, MI, Last)
Age
Sex
Relationship to Applicant
Birthdate
SECTION III – HOUSEHOLD FINANCES Please give complete and accurate information. Attach copies of proof of income. More space available on back. Which household members receive income and what type? _______________________________________________________ Employer name: __________________________________ Hours worked/Week: ____________ Hourly Wage: $_____________ Employer name: __________________________________ Hours worked/Week: ____________ Hourly Wage: $_____________ Monthly Household Income
Monthly Household Expenses
Wages & Side Jobs:
$
Food:
$
SSI, SSA, Disability:
$
Transportation:
$
Unemployment or Workers’ Comp:
$
Child Care:
$
TANF/ FI:
$
Medical:
$
SNAP/Food Stamps:
$
Housing and Utilities:
$
Child Support/Alimony:
$
Loan payments:
$
Other, please explain:
$
Other, please explain:
$
Total:
$
Total:
$
APPLICATION CONTINUES ON BACK FOR OFFICE USE ONLY: Date Rec’d & by: _________________ Complete? ___ Action? ________________ Date Cmplt: ________ Qualified? N Y Amount? 25% 50% History OK? _____ History notes: ___________________________________________ Total Cost of Request: $_____________ Amount to be Paid by Participant: $_____________ Amount of Assistance: $_____________ Date Approved & by: ________________ Date Mailed & by: ________________ Phone Asmnt/Interview Date: __________________ Notes: _____________________________________________________________________________________________________ The Salvation Army Ray & Joan Kroc Corps Community Center - P.O. Box 921 - Augusta, GA 30903 - Phone 706.364.KROC (5762) - www.krocaugusta.org
SECTION IV – PARTICIPATION REQUEST Please tell us the amount that you are able / willing to pay towards your monthly household membership: $__________________ What do you want to do at the Kroc Center? How will your household benefit from an Income Based Kroc Center Membership? Attach no more than one page if needed.
ADDITIONAL INFORMATION Please use the space below for any additional information that did not fit in other areas of the form.
This application and all required documentation are confidential information and will be used only by authorized staff for the purpose of processing Kroc Center Income Based Membership applications. By signing below you agree that all information provided is accurate and complete. Any information found to be incomplete, fraudulent, or false will result in this application and any memberships issued from it being cancelled. Additional penalties related to participation at the Kroc Center may be given at the discretion of management. Signature of Applicant: ___________________________________________________ Date: ___________________________ Please complete all sections and attach copies of proof of income. Incomplete applications cannot be processed.
The Salvation Army Ray & Joan Kroc Corps Community Center - P.O. Box 921 - Augusta, GA 30903 - Phone 706.364.KROC (5762) - www.krocaugusta.org