Scholarship Request Form - English
Scholarships are based on a sliding scale. Form must accompany your HOUSEHOLD last 3 paystubs or last tax form.
(1) Member's Name
*
First Name
Last Name
Member Date of Birth
*
Month/Day/Year
(2) Member's Name
First Name
Last Name
Member Date of Birth
Month/Day/Year
(3) Member's Name
First Name
Last Name
Member Date of Birth
Month/Day/Year
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
Sliding Scale Assistance Needed for the Following Program(s):
*
Youth Membership
Performance Team Membership
Find The Fun
Summer Enrichement Program
Please indicate Yearly HOUSEHOLD Income & Scholarship level (proof of income is required)
*
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 proof in person.
Signature
*
Clear
Submit
Should be Empty: