2021 Completed form with payment should be placed in an envelope and submitted to Diana Riolo Adult Sponsor 1 First name Last name DOB ID: 849503
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1 2021 - 2022 FAFU CHILD SPONSORSHIP APPLI
2021 - 2022 FAFU CHILD SPONSORSHIP APPLICATION (Completed form with payment should be placed in an envelope and submitted to Diana Riolo.) Adult Sponsor #1 First name: _______________________ Last name:__________________________ DOB:_________ Age:_________ Phone:_______________________ Email: _____________________________________________________________________ Adult Sponsor #2 (if splitting Sponsorship) First name: ________________________ Last name:__________________ _______ DOB:___________ Age:_________ Phone:_______________________ Email:______________________________________________________________________ Additional Adult Members in sponsoring household: Name:________________________________________ Name:________________________________________ Children in sponsoring household: Name & Age:_________________________________ Name & Age:_________________________________ Name & Age:_________________________________ SPONSORSHIP OPTIONS: ____One sponsorship @ $360 / per child ____Split a sponsorship @ $180.00 / per sponsor, per child (2 committed participants required at time of registration) ____one - time donation without committing to maintaining contact with a child at FAFU If you would like to sponsor a specific child(ren), please print name(s) below. If no name(s) is(are) listed, the YMCA will assign a child(ren) to you. _________________________________________________________________________________________________________ We would like to share your experience: If you would like to remain anonymous, please check here ______ PAYMENT INFORMATION ____Check Amount ____________Check #:__________ _______ Date:___________________ ____Cash Amount: ___________ Date:____________________ ____Credit Card Amount: _____________ Card Type AMEX DISCOVER MC VISA Card #: ________________________________________ Exp. Date: __________ CVV_________ An acknowledgement letter for tax purposes will be mailed to you .