FEE ADJUSTMENT FORM

Player Name *

First

Last

Player Gender *

Male
Female

Current Grade *

Parent Information

Please fill out this section completely.

Parent Name *

First

Last

Email *

Cell Phone *

Program Cost Adjustment Request

Fill out the corresponding sections that best describes your situation.

Level Up Hoopers Sessions *

How much can you afford for this program? *

Clinic/League Payment: Do you need the fee dispersed into multiple payments for each session? *

Yes, I need a split payment option
No, I want a one-time payment
N/A (Clinic / League Fees)

Other Circumstances (Optional)

In the Space below (or typed on a separate page, or in an email), please describe any other reasons or circumstances (past, present, or future) that you feel increase your qualification and/or need for financial assistance at Level Up Hoopers (e.g., family circumstances, income hardship, conflicting logistics, other restrictions; etc.).

Reason or Circumstance:

Conditions Upon Acceptance

If your application is accepted, understand that the scholarship & financial discount offered to you from Level Up Hoopers is conditional and that to continue receiving the same you (and the awarded player) must:

a. Maintain credible behavior and conduct in accordance with Level Up Hoopers standards.

b. Payments must be on time. Any unsuccessful payments or past due accounts must be rectified within one week.

c. Inform Level Up Hoopers administration when the need for adjustment no longer exist.

Level afford dispersed

Signatures

I affirm that the information in this form is true and accurate according to my knowledge.

Parent Signature *

Type Full Name

Date *

Thank you for your scholarship application!