Rider Assistance Application Form

Rider Financial Assistance Application

Through fundraising activities and grants from private foundations, Main Stay is able to offer assistance to qualifying clients on a sliding scale based on income. Main Stay uses the income levels as established by the Illinois Free and Reduced Lunch Program. Current information on these income levels is listed below.

  • Riders who meet the criteria for free lunch based on income level will pay $10 per lesson.
  • Riders who meet the criteria for reduced lunch based on income level will pay $15 per lesson.

Riders will be eligible to apply for funding each year, however, funding may only be awarded to eligible riders for up to three years. Funds are limited and will be awarded based on the sole discretion of Main Stay. Riders must stay current with their payments and may lose their assistance due to excessive cancellations or nonpayment.

Financial assistance may be awarded for 1, 2, or 3 riding sessions of the current year based on the number of sessions selected by the rider. The same lesson fee is applicable for all sessions.

Riders need to complete a Financial Assistance Application annually and assistance is not guaranteed each year.

  1.3 (Free Lunch)
$10/Lesson
1.85 (Reduced Lunch)
$15/Lesson
Family of 1 16,744 or less 23,828 or less
Family of 2

22,646

32,227
Family of 3 28,548 40,626
Family of 4 34,450 49,025
Family of 5 40,352 57,424
Family of 6 46,254 65,823
Family of 7 52,156 74,222
Family of 8 58,058 82,621
Client Name
Client Name
First
Last
Client resides with
Client's marital status
Client submits his/her own Federal and State taxes?
If no, who claims the client for tax purposes

The client or individual who claims the client for tax purposes must submit a current income tax return along with the application.

Please list the amount received from each of the following sources for all family members that apply:

$
$
$
$
$
$
$
Which session(s) are you requesting financial assistance?

The Mental Health Resource League is a large contributor to our Rider Assistance Fund. Volunteers are needed for their craft fairs and the funds given to Main Stay are directly related to the number of volunteers who assist at their events.

Please indicate which fundraising activity you will participate in
Maximum upload size: 3.15MB

Information provided in this application will be kept confidential.

I certify that the information provided in this application is correct to the best of my knowledge.