Sliding scale yoga classes

To apply for sliding scale fees:
1. Please complete the form below
2. Print the completed form, and attach requested supporting documentation
3. Mail the form and supporting documents to us at 1635 Connecticut Avenue NW, Washington DC 20009

Sliding Scale Application Form

All information is confidential.

Name:
Email:
Phone:

Address:

Employer Name (if any):

Employer Address:

Monthly net income from work (after taxes)     $
Monthly public assistance checks (SDI, Welfare, etc.)     $
Monthly unemployment compensation    $
Any other monthly or annual income (such as a second job)     $
TOTAL NET INCOME $

How many adults are supported by this income:
How many children are supported by this income:

DOCUMENTS REQUIRED:
Yoga District requires written verification of your monthly income such as pay stubs, income tax return or AFDC form. We also require written verification of extraordinary expenses (i.e. medical/dental costs) such as a bill, receipt or check stub. Please provide a copy of the main pages of your last tax return.

OUR HONOR:
Yoga District is a nonprofit organization, and our class proceeds are dedicated to furthering yoga outreach at Yoga District studios and outreach locations including homeless shelters, trauma survivor organizations, detention centers, schools, and other public service nonprofits and agencies.

YOUR HONOR:
Information which I have provided above is accurate and complete. I agree to notify Yoga District if there is any change in my income or expenses which would affect my eligibility for the sliding scale discount within 5 days of those changes.

Signature of parent/guardian or adult student: ________________________

Date: ______________