Sliding scale yoga classes

To apply for sliding scale fees:
1. Please complete the form below.
2. Print the completed form, and attach all requested supporting documentation.
3. Mail the form and supporting documents to us at 1910 14th St NW, Washington DC 20009, ATTN: Jasmine
4. Given the high volume of inquiries we receive, it may take a few weeks to process your application. Please do not call to check the status of your application; rest assured that we are working on it.

**If you are applying during government shut down as an affected contractor or employee, you may choose to not fill out questions 1 through 5. For documentation, please send proof of furlough.**

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:

Monthly rent or mortgage:

Current amount of financial assistance received per month, including food stamps:

Names, relationship, annual income and contact information of individuals who have provided financial assistance to you in the past 12 months:

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, evidence of your receipt of government or other financial assistance, bank account statements, credit reports, and other documents that will help establish your financial situation.

Additionally, please include a short essay (500 words minimum) sharing experiences and insights about your yoga practice. Possible essay topics: why you began practicing yoga, how you incorporate your practice into every day life, what you’ve learned from your yoga practice, etc.

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:
I swear under penalty of perjury that all information which I have provided above and in attached documents 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: ______________