Ohio AAA Blue Jackets Grant Application

(with support from the Columbus Blue Jackets Foundation)

The Ohio AAA Blue Jackets Grant is intended to assist in providing funds to players in financial need and might otherwise be unable continue to play ice hockey due to family financial circumstances or other special circumstances. Each application will be evaluated for recommendation on an individual basis by the AAA Blue Jackets Board. All applications must be completed in full, signed and mailed to:

AAA Blue Jackets, 5997 Round Tower Lane, Dublin, OH 43017

ALL INFORMATION IS CONFIDENTIAL. USE BACK OF APPLICATION OR ADDITIONAL SHEETS IF NECESSARY.

DATE: _______	Age division (Please circle – GIRLS, SQUIRT, PEEWEES; BANTAMS; MIDGETS)

Applicant’s Name: _____________________________________________	Date of Birth: __________________

Email Address:___________________________________________	# of Dependants Claimed: __________

Cell Phone:______________________________________________________________________________________

Last year’s reported Adjusted Gross Income: _____________ (copies of prior two year’s tax return must be included)

Did you participate in any spring/summer hockey: Please circle one: Yes No If Yes, with who?_______________

Do you participate in private hockey lessons? Please circle one:	Yes	No

How much financial assistance are you seeking?:________________________________________________________

How much are you able to pay for hockey?__________________________________________________________

(Parent/Guardian) Please give a description as to why special extenuating circumstances may apply:

________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________

(Please include the most recent grade card for your player)

If a Grant is approved for a family, community service hours for the Columbus Blue Jackets Foundation will be required.

Player and/or Parent/Guardians: Would you be willing to sell web site sponsorships in support of your AAA Blue Jackets Grant? Please circle one:	Yes	No

Parent or Guardian Signature: ______________________________________________________ Date: __________	(MUST BE SIGNED FOR APPLICATION TO BE CONSIDERED)