ࡱ > 6 8 5 > bjbj $ = D D # " ? ? ? ? ? v v v 6 8 8 8 8 8 8 $ {! \ $ ^ v $ $ \ ? ? q $ R ? ? 6 $ 6 " ? 3 4 X " 0 " B " " H v > , $ v v v \ \ v v v $ $ $ $ " v v v v v v v v v D M : School of Teacher Education 1906 College Heights Blvd #61030 Bowling Green, KY 42101 Phone: (270) 745-4607 Fax: (270) 745-6435 Email: literacy.clinic@wku.edu Literacy Clinic Tuition Application Clinical fees/tuition will be determined on an individual client basis. Fees range from a minimum of $25.00 to $150.00. If needed, a payment schedule can be arranged for the semester. Please read all instructions carefully and return. Student Name: _________________________________________________________________________ last first middle preferred name Parent/Guardian Name(s):_________________________________________________________________ Home Address: ________________________________________________________________________ Street, Route, P. O. Box City State Zip Code School: ________________________________ Grade: ________________________ (if applicable) Number of siblings under 18 living at the above home address: _________ Year/Term you will attend the clinic: Year ________ Fall (Aug) ___ or Spring (Feb)___ Have you or will you apply for any outside grants sponsored by an organization not affiliated with the WKU Literacy Clinic for your childs tuition? _____ If yes, list organization(s): _________________________________________________________ Please attach a copy of your W-2 or current paystub. (All information is kept confidential.) Please provide any additional information that may apply to your financial need: ___________________________________ _________________ Signature of Parent/Guardian Date For Office Use Only: Amount : ________ Semester: ______ 6 = > V ^ 5 F d } @ A õޯޫޫޫޫ~w~w~rw hq ` 6hq ` 56 h 56 hq ` 6CJ h{d@ h h h CJ OJ QJ hq ` CJ OJ QJ hq ` h CJ j h{d@ UmH nH u )j h{d@ 6CJ OJ QJ UmH nH u h CJ hq ` CJ h.= CJ hL CJ hZ CJ hq ` 6OJ QJ , > V \ 4 ` gd $a$ $a$ $a$gd 4 E F @ A A ( ) 1 ; > hq ` CJ hq ` 6CJ h hq ` 6CJ hq ` CJ h 6CJ hq ` 5CJ OJ QJ hq ` h{d@ ) : ; < = > 2 1:p{d@ / =!"#$% F Ja1nD)) JFIF H H C (1#%(:3=<9387@H\N@DWE78PmQW_bghg>Mqypdx\egc C//cB8Bcccccccccccccccccccccccccccccccccccccccccccccccccc n " } !1AQa"q2#BR$3br %&'()*456789:CDEFGHIJSTUVWXYZcdefghijstuvwxyz w !1AQaq"2B #3Rbr $4%&'()*56789:CDEFGHIJSTUVWXYZcdefghijstuvwxyz ? ( ( (*^ai-˄1?^_xP%)o#[#l3tZX)!pfq#@yg DJy^ۣG+ecUQ@_AYGujq{P}y,YBe#C(*wPKq4ȭ,;|W=3P( yymcw
VꥅƯ<[FR9oִl-q cպ ֯+Bp45>KI
ʰ؊MgBg)uJ( (=#Cnv1\<"}O@/WmB"D"A Z4tm:;Hy˹zK1 Oj uIKHLW
+Bo6Jc# -lD5icy3^af9, Fj^ܷ729ʞA_Y|Eiq$)$
]g z5q5SYnt190{|OIp3
{Z<gT!y? i7aDzcC(JE`9 cȅ$Px* ='~ -B ^DH$jG@ S(>OSGoPe#)/8*[x% 6W;UTrM G,"@1
$W_@ԬI-J=EJ SxW°谉%_<=Okܟmw>ӆZmě7 ^mGX 0đ
*)YR4fc=*b $@ɳòt?.lڀ:Y$Ԁ4ay+JZ ( +`oe^}~ץ!'`^k/:ڌdu b<ͮۨ3@3;bY$L
vĉ41 AU]UvںmoO!)41 rMz<0<jPײ?zST<9-$2 ] QE y/O8$[V O &dD~X:
wmfg<.N3#>#_^ɣ],D:G^E gYk7hv3V$6Om5f {}Vnۯ1sʼnGI>9U Shj(