Financial Assistance Evaluation Form

Child First Name    Child Last Name    Address   
Zip Code   
Phone (of Parent)   
Email (of Parent)
Reason for application    Amount requested    How did you hear about us? Applicants should meet the following criteria: (check all that apply)

Do you currently qualify for, or already receive:

Extenuating Circumstances

At times, a child's family may not qualify for financial assistance under the stated income guidelines, but has experienced extenuating circumstances that the Team Mojo Foundation will consider when determining eligibility.

Examples of extenuating circumstances: (check all that apply)

Extenuating Circumstances Description (the more information we have the better): Parent/Guardian Name:

By clicking Submit the undersigned agrees that all information provided is honest and accurate and does jointly and severally agree to indemnify and save harmless TEAM MOJO FOUNDATION from any claim, action, liability, loss, damage or suit, arising from activities related to the financial assistance provided.