Tuition Assistance Application
Through our Tuition Assistance Program we aim to assist low or moderate-income families, families in special circumstances, or families with two or more children in childcare.  Heath Extended Day does not discriminate on the basis of race, color, creed, religion, cultural heritage, national or ethnic origin, age, handicap, sex, marital status, or political beliefs.
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Email *
First Name and Last Initial of Parent(s) *
Jane & Joe D.
Please read before filling out the form:
All applicants should contact Noelle Ahearn at noelle_ahearn@psbma.org once the application is complete.

Paper Applicants can also be accepted.

All families who receive waivers from the Town of Brookline can skip this step and submit their verification forms from the Town of Brookline.

Tuition Assistance partnership guidelines suggest applications be submitted no later than September 15th for the first semester and January 15th for the second semester.

This form was made using Google Forms.
Child's/Children's First Name(s) *
Grade *
Required
# of Days per Week at HEDP *
If you have multiple children please use the "OTHER" option to specify desired days.
Required
Address
Phone # *
Email Address *
Please list ALL members of your household followed by a) date of birth b) occupation/school c) name of employer, if employed *
Are any members in your household receiving Medicare or Medicaid? *
If so, please list the names of ALL Medicare/Medicaid recipients below, followed by their Identification #
Does/Do your child(ren) receive free or reduced lunch through the public school? *
Please include all Assets below
Average monthly Checking Account balance *
Total Savings Account balance *
Total Securities (mutual funds, IRA's 401k's) *
Assessed Value of Real Estate *
Other Assets (cars, boats, vacation property) *
Total Assets *
Additional Comments
Sources of Income
Please list all sources of income per MONTH below and any aid received (AFDC, Flat Grant, Child Support etc.)
If not applicable leave blank.
Please list the Gross Monthly Income from each household member's current position/job *
Please select any/all organizations that currently offer your family aid *
Required
If you made any selections, please specify how much aid/compensation you receive from any/all organizations.
Total Monthly Income *
Monthly Expenses
Please list all monthly expenses below. If not applicable leave blank.
Rent/Mortgage
Phone/Internet
Heat
Electric
Medical
Health
Dental
Car
Food
Clothing
Insurance
Homeowners/Rental Insurance
Life Insurance
Auto Insurance
Other (Student Loans, Outstanding Debt, Cell-phones etc.) Please List ALL other monthly expenses.
Total Monthly Expenses *
Gross Monthly Income *
Special Circumstances/Community Aid
Have you tried to find aid elsewhere (Child Care Choices of Boston, Community Partnership Programs, Church, Local Organizations, Your Employer) If so, what was the outcome?
Are there any special or unusual circumstances not reflected in the figures preceding that would be important for us to know to determine your eligibility?
The above information is, to the best of my knowledge, true and accurate. I understand that misinformation may result in my disqualification from this assistance program. I also agree to notify the Director if there is any improvement in my financial status over the course of  the year, if I am granted assistance.
Do you agree with the above statement? *
Please Read before completing this form
Heath Extended Day aims to assist low or moderate-income families, families in special circumstances, or families with two or more children in childcare. Heath Extended Day does not discriminate on the basis of race, color, creed, religion, cultural heritage, national or ethnic origin, age, handicap, sex, marital status, or political beliefs.

Tuition Assistance offered by Heath Extended Day is a partnership that draws on the combined resources of the family and our limited tuition assistance funding. The Heath Extended Day Program believes that the primary responsibility for payment, lies to the extent possible, with families themselves. We offer tuition assistance on a semester basis and encourage all families to apply during the 1st semester (September 10th) and 2nd semester (February 10th).

Heath Extended Day is almost exclusively funded through tuition and offered on a need basis, making funding for Tuition Assistance unpredictable from year to year. Therefore, Heath Extended Day is unable to award families more than 50% of their total tuition costs. Eligibility for tuition assistance is highly confidential and is determined by a committee that is only presented with facts and numbers from the director. We take pride in keeping true to our confidentiality statements.

The Heath Extended Day Program understands that for some families it may be easier to pay over more than monthly predictable payments. Therefore, the Heath Extended Day Program Bookkeeper and Director are available to create such a payment plan if requested.

If you wish to submit a Tuition Assistance Application at this time, please review all materials including the State Medium Income Guidelines, complete the full application below, and mail or drop off all necessary pay-stubs/paperwork to the Director as soon as possible. The tuition assistance committee will meet and make decisions by as applications are received. If you have any questions or concerns, please phone Noelle at 617-879-4565.

Thank you for your cooperation.
To complete the application, please submit the following to the Heath Extended Day Program director at noelle_ahearn@psbma.org or a hard copy can be dropped off in person:
2 Pay Stubs for each working household member, 1 gas bill, 1 electric bill, 1 rent/mortgage receipt, Medical/Dental statements, Insurance statements, Current Bank statements, and any other information that you feel would assist in the determination of your application.
Thank you!
First Name and Last Initial of Person Completing the Form *
Ex: Jane D.
Today's Date *
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