EP&R

 

· Scholarships are available for participants 17 and younger.

· Scholarships limited to 2 classes per child per season/brochure.

· A copy of last year’s income tax return must accompany this form.  Any and all earned AND unearned household income must be included.  Some examples of unearned income include: alimony, child support, unemployment insurance, retirement pension, student loans, foster care program, food stamps, and rent.

· The scholarship form must be completed by a parent, guardian, or head of household of enrolled participants.

· Scholarship applications and registrations will not be processed without ALL of the requested information.

· Some activities are exempt from the scholarship, i.e. trips, contract employees and co-sponsored events.

· Approval of a scholarship fee does not register the participant in the activity.  A completed registration form and allocated fees must be received upon enrollment.  Please have scholarship forms completed 2 weeks prior to the class or program.

Please fill out application completely!

Please Print:

 

Applicant’s Name: _______________________________ Spouses Name: ____________________________

 

Address: _______________________________________ City, State, Zip: ___________________________

 

Work Phone: ___________________________________ Cell Phone: _______________________________

 

Email: _________________________________________ Child’s Name: ______________ DOB __________

 

Monthly Income $______________________ x 12 months Child’s Name: ______________ DOB __________

 

Annual Household Income: $______________________    Child’s Name: ______________ DOB __________

                                             *earned and unearned          

 

Total Number of Dependents _________

 

Total amount of assistance requesting: $ ______________________

 

The Eudora Parks and Recreation Department reserves the right to request proof of any of the above information.  Failure to supply the necessary information could result in denial of financial assistance.  If an activity uses supplies, facilities (schools) or issues equipment that is not returnable, applicants will be asked to at least cover the cost of those supplies, facilities and/or equipment.

 

_____________________________________                                                                 _________________________

Signature                                                                                                                                 Date

 

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