Financial Assistance Application

Financial Assistance Application

If you have any questions, contact NPRD @ director@norwoodparkandrec.org or 970-327-1048.
Confidentiality:

The District will keep all application materials confidential and will not share the application materials with other individuals, organizations or agencies without your express approval. Only District staff who review and approve scholarship applications will have access to the submitted materials.
Are you filling out this application for someone else?*

YesNo
Adult/Primary Guardian Information
Name*

First NameLast Name
Date of Birth*
Home Phone Number*
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Email Address*
example@example.com
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employed by:*
Gross Monthly Income $*
Other Income $*
Household Assistance Received (check all that apply)*

SNAPFree MealsWICCCCAPNone
How many people are in your household?*

You must provide documentation in order to determine eligibility.

You may do this by submitting one of the following:
1) Current eligibility/award letter for SNAP, CCCAP, WIC, Free Meals 2) Copy of most recent Federal 1040 income tax returns, OR 3) If you are unable to provide either of the these, you may submit other documentation of income (SSA/SSI Benefit Statements, or last 3 months of paycheck stubs, etc.)

Please list all dependent children age 18 and under.
Dependent Name #1

First NameLast Name
Birth Date

MonthDayYear
Gender
Dependent Name #2

First NameLast Name
Birth Date

MonthDayYear
Gender
Dependent Name #3

First NameLast Name
Birth Date

MonthDayYear
Gender
Dependent Name #4

First NameLast Name
Birth Date

MonthDayYear
Gender
If you have additional dependent children to declare, please list names, ages and genders here:

I certify that the above information is true and correct and that all household income is reported.

I will notify Bend Park and Recreation District of any changes in income or family size. I represent that I am a resident of the City of Bend or the surrounding area. I understand that providing false or incomplete information to the District will immediately lose their financial assistance.
Signature of Applicant*
Name of Applicant*
First & Last Name
Phone Number*
Additional Comments
Should be Empty:

Confidentiality: