Sioux River United Summer Soccer Discount Application

(Please Print)

Social

NAME _____________________________________________Security # _________________

(First) (M. I.) (Last)

ADDRESS_______________________________City________________St_____ ZIP _____

1. I am applying for a discount of Sioux River United (SRU) registration fees for my child ________________________, to be effective for the 2008 summer season. I understand that this application will be reviewed by the SRU executive officers and I agree to pay a minimum of $30.00 toward the registration fee. I (or my family members) will volunteer an additional 8 hours of concession stand coverage during the April through October timeframe.

2. To determine my immediate family eligibility, I am stating that I qualify for the requested discount because:

A. I participate in the program(s) checked below; I agree to furnish proof of my
participation to SRU:
_____ Medicaid (not the same as Medicare)

_____ Food Stamps

_____ Supplemental Security Income (SSI)

_____ Federal Public Housing Assistance

_____ Low-Income Home Energy Assistance

_____ Temporary Assistance for Needy Families (TANF)

_____ National School Lunch (NSL) free lunches

I CERTIFY UNDER PENALTY OF PERJURY THAT THE ABOVE INFORMATION IS TRUE. I have read the information above and understand how I must qualify to receive the SRU registration discount. I also hereby authorize the administrative office for any program indicated above to verify my participation to SRU.

______________________________________________ ________________________

Signature Date