Summer Adventure Scholarship Application Form
Child #1 Full Name
First Name
Last Name
Child #1 Date of Birth
-
Month
-
Day
Year
Date
Child #2 Full Name
First Name
Last Name
Child #2 Date of Birth
-
Month
-
Day
Year
Date
Child #3 Full Name
First Name
Last Name
Child #3 Date of Birth
-
Month
-
Day
Year
Date
Child #4 Full Name
First Name
Last Name
Child #4 Date of Birth
-
Month
-
Day
Year
Date
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Family Information
Does at least one Parent/Guardian live or work in Summit County, UT?
Please Select
Yes
No
Parent/Guardian 1
Parent/Guardian Name
First Name
Last Name
Cell Phone
-
Area Code
Phone Number
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian 2
Parent/Guardian Name
First Name
Last Name
Cell Phone
-
Area Code
Phone Number
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Income Information
How many total children do you have in your household?
How many total adults do you have in your household?
How many adults (within your own household) work full time?
How many adults (within your own household) are unemployed or work part time?
What is your TOTAL annual household income?
$
Is there additional information you would like us to know?
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Confirmation
By signing or typing my full name, I attest that the information provided is true and accurate.
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