Candidate First Name    Candidate Last Name    Address    Purpose of application    Amount requested    How did you hear about us? -- Select -- Billboard Coach Facebook Friend Newspaper Other Sticker T-Shirt Teacher Twitter Website Candidates for financial assistance should meet the following criteria: (check all that apply) Reside and/or attend school (K-12) within the Team Mojo Foundation coverage area.
Be 18 years old or younger (can be older if still in high school).
Be a legal dependent of a family living under the Federal Poverty Guidelines. Do you currently receive: HEAP
Food Stamps
HUD
Medicaid
SSI
School Lunch Program
Head Start
Other Government Assistance

Extenuating Circumstances

At times, a candidate'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) Recent loss of essential income upon which the family has depended.
Significant medical expenses not covered by insurance.
Loss of, or severe damage to, a home or family business due to natural or other disaster, which insurance didn't cover.
Other hardships that qualify as extenuating circumstances impacting family income. 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.