Scholarship Request Form - English
Scholarships are based on a sliding scale. Form must accompany your HOUSEHOLD last 3 paystubs or last tax form.
Parent/Guardian Name
*
First Name
Last Name
E-mail Address
*
Phone Number
*
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
(1) Childs Name
*
First Name
Last Name
Member Date of Birth
*
Month/Day/Year
(2) Childs Name
First Name
Last Name
Member Date of Birth
Month/Day/Year
(3) Childs Name
First Name
Last Name
Member Date of Birth
Month/Day/Year
Sliding Scale Assistance Needed for the Following Program(s): *Please note: scholarship assistance is prioriized for monthly memberships and not applicable to drop-in classes or sessions.
*
Youth Membership
Performance Team Membership
Find The Fun
Summer Enrichement Program
Please indicate Yearly HOUSEHOLD Income & Scholarship level (proof of income is required prior to scholarship award):
*
Less than $19,999
$20,000 - $29,999
$30,000 - $39,999
$40,000 - $49,999
$50,000 - $59,999
$60,000 - $69,999
Number of Children
*
1
2
3
4
5
6
Change in situation or Emergency need
My Family is in Need of an Full Tuition Emergency Response Scholarship.
Scholarship amount will be awarded upon verification of income. Please provide 3 recent paystubs or tax forms as proof in person.
Signature
*
Submit
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