3.g 1-1-19 Form CITY OF SCANDIA PARKS AND RECREATIONDRAFT 2 DRAFT 2 DRAFT 2 DRAFT 2
CITY OF SCANDIA
PARKS AND RECREATION
RECREATION PROGRAMS SCHOLARSHIP - 2019
An adult household member must complete this application before registering for any
programs or activities to receive Program Scholarship. Only one form, per family, is needed
for each calendar year. Scholarships are contingent upon scholarship fund balance. All
information submitted will remain confidential.
Submit completed form to: City of Scandia, 14727 209th Street, Scandia MN 55073
PARTICIPANT INFORMATION
Adult Applicant Name:____________________________________________
Address: ________________________________________________________
City/State/Zip:____________________________________________________
Phone: ____________________________________________________
Email Address:_________________________________________________
TOTAL HOUSEHOLD INCOME
Is your family currently on any form of public assistance? Yes No
Indicated number of persons living in your household? 1 2 3 4 5+
Annual Household Income: $ __________________ (Annual Household Income includes:
wages, tips, social security, public assistance, interest, etc.)
Basis for request of Program Scholarship:
__________________________________________________________________
__________________________________________________________________
Within the last 12 months has there been a financial hardship for your family?
Yes_____ No_____ If “Yes”, Explain
____________________________________________________________________________
____________________________________________________________________________
APPLICATION INFORMATION
Participant’s Name Date of Birth
I attest that to the best of my knowledge all of the information provided on this form is
current and correct:
Parent, Guardian, or Adult Participant Signature
Date:
Upon approval of Program Scholarship, participants will not be registered or added to any
program rosters until your 1/3 portion of the program fee is received.
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FOR OFFICE USE ONLY
Eligibility Determination:
Approved Denied
If denied, indicate reason:
Comments:
City of Scandia Staff Signature/Title Date