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RSMS Financial Assistance Request Form 2021-2022
*CONFIDENTIAL*
Rockwood South Middle School
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* Indicates required question
Email
*
Your email
Student(s) First & Last Name(s)
*
Your answer
Student(s) Grade(s)
*
6th Grade
7th Grade
8th Grade
Other:
Required
Parent/Guardian Name(s)
*
Your answer
Telephone #
Your answer
# of Family Members living in the home that are adults
Choose
1
2
3
4
5
6
7
8
9
10
# of Family Members living in the home that are children
Choose
1
2
3
4
5
6
7
8
9
10
Please check here if you’d like to receive emails about free or low cost upcoming events or resources (i.e. free night at the magic house, free oil change, free meals at restaurants, etc.)
Yes, I'd like to receive these emails.
AREAS OF POSSIBLE ASSISTANCE*
*Financial Assistance is not guaranteed and will be determined based on funding and opportunities available.
Please check any area(s) that we could possibly provide assistance in.
RSMS Food/Toiletries Pantry (social worker will contact you to see if you want bag to go home with your student or parent pickup on Fridays)
Academic program/field trip assistance (Please fill out which program you need assistance with below - Social Worker may need to notify teacher of request)
School Supplies (please list what supplies is needed below)
New or Gently used Clothing
Other:
If you indicated your child needs school supplies, what supplies are needed?
Your answer
If you indicated your student needs financial assistance with an athletic program or field trip, is there a specific program or field trip? How much financial assistance is needed?
Your answer
If you indicated your child needs clothing, what items and sizes are needed?
Your answer
FINANCIAL STATUS
Please list dollar amount by Monthly Income for any/all that apply.
Earned Monthly Income: $ (full-time/part-time)
Your answer
TANF:
Your answer
Child Support:
Your answer
Unemployment:
Your answer
SSI: $
Your answer
ADDITIONAL CIRCUMSTANCES
Please check all that may apply.
Unemployed parent
Eligible for free/reduced lunch
Homeless/in transition
Single Parent
Illness
Other (please describe below)
Upon submitting, this Google Form goes to the RSMS Social Worker, Ashley O’Daniel. If you have any questions, please contact Ashley at
odanielashley@rsdmo.org
or 636-891-6879.
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