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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. --------------------------------------------------------------------------------------------------------------------------- FOR OFFICE USE ONLY Eligibility Determination: Approved Denied If denied, indicate reason: Comments: City of Scandia Staff Signature/Title Date