LBAScholarhip Application

Office Use Only Received by

DateTime

Date

Address

Phone Number

Email

example@example.com

Family Type ex single parent twoparent multigenerational etc

Rent

Own

Other

Were you and your family heavily affected by the Hurricane

Please list everyone living in the household below

Last NameRelationship toGender Head of Household Self

Birthdate RaceLevel ofDisabled Education(Yes or No)

Child(ren) who need scholarships:

Name of Program Example: Winter Art Camp

Cost (Weekly cost and number of weeks)

Required Attachments for complete application: 1) Copy of completed form 2) Copy of Driver's License for Head of Household 3) Documentation of the last 90 days of income for each person over the age of 18 (paystubs from the last 90 days, SSI letters, child support documentation, etc

By signing this application, I certify that the information given is true and accurate. I understand that any false information will result in my disqualification from this program.

Applicant signature

Date

In consideration for being allowed to participate in this Activity, I release from liability and waive my right to sue LBA LLC., their employees, officers, volunteers, and agents (collectively "District") from any and all claims, including claims of the center's negligence, resulting in any physical injury, illness (including death) or economic loss I may suffer or which may result from my participation in this Activity, travel to and from the Activity (including air travel), or any events incidental to this Activity.

Please note that approval of scholarship funds does not guarantee a spot at your preferred program. Please refer to the program you have chosen to check your child's status. We review attendance logs from the programs we work with - if your child fails to attend, you may be liable for repayment of this scholarship and may become ineligible in the future. The family is responsible for any cost over and above the qualified scholarship amount.

Signature

Date

Printed Name

Number in Family	125% of Poverty (up to $1000/child scholarship)	200% of Poverty (up to $500/child scholarship)
2	$24,650	$39,440
3	$31,075	$49,720
4	$37,500	$60,000
5	$43,924	$70,280
6	$50,350	$80,560
7	$56,775	$90,840
8	$63,200	$101,120

Total Gross Income Guidelines:

Name