Financial Assistance - Add Purchasing Group
Financial Assistance - Add Purchasing Group
Use this form to add a financial assistance purchasing group to member account.
Applicant Name
Applicant Name
*
First
Last
Customer ID
*
Location:
*
Central
El Camino
East Palo Alto
East Valley
Northwest
Mount Madonna
Palo Alto
Redwoods
Sequoia
South Valley
Southwest
Youth Development
Membership
Membership Type:
Single Adult
Single Adult w/ dependents
Two Adults
Two Adults w/ dependents
Three Adults w/ or without dependents
Young Adult/Youth
Senior
Two Seniors
Discount Applied (70% requires Executive Director approval)
30%
50%
70%
Start Date
Start Date
/
MM
/
DD
YYYY
End Date
End Date
/
MM
/
DD
YYYY
Program Type:
Program Purchasing Group
YD_CAMP
YD_SCHOOL_YR
BRANCH_PRG
HEALTH_FITNESS
OUTDOOR_SCIENCE
CAMP_CLIENT_GROUP
FACILTY_RENTAL
Discount Applied (70% approval requires Executive Director approval)
30%
50%
70%
Start Date
Start Date
/
MM
/
DD
YYYY
End Date
End Date
/
MM
/
DD
YYYY
Staff submitting form:
Staff submitting form:
First
Last