Scholarship Application Form
  • Scholarship Application Form

  • Today's Date*
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  •  Scholarship Process: 

    The Sebastopol Area Senior Center is pleased to offer scholarships based on our mission. We offer a wide variety of services and programs to the Sebastopol Area community at reasonable prices. 

    Scholarships are available to Sonoma County residents who qualify, based on financial need. (Must be 60+ years of age). This scholarship can start or renew an SASC membership, however you must apply every year. Scholarship recipients receive a $50 membership and $50 towards SASC programs and activities. 

    Funds awarded are not transferrable and must be used within 12 months of the date on this form. All unused funds will be returned to the Senior Center. 

    Scholarships are offered based on need and at the discretion of the Senior Center. Scholarships are not always available. However, when they are, we are very pleased to provide them. 

    How to apply: 

    Complete the information on this form. All information is kept confidential.
    Scholarship applicant must become a member. Funds will be used towards membership fees. Funds are not available for same-day activities. Credits will not be awarded for missed classes or late cancellations. Scholarship applicant will be notified of scholarship status within 5 business days.

    Visit our Website HERE 

    Our Weekly MENU for the Harvest CAFE

    Check out our daily activity calendar HERE

  • Please read and check each box as*
  • My need for scholarship or reduced payments is evident by the following:*
  • Personal Information

  • Format: (000) 000-0000.
  • Your Birthdate:*
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  • More Information:

  • Are you a Veteran?*
  • Are you Married?*
  • Do you live alone?*
  • Do you live within City limits? (If you receive a City of Sebastopol water bill, you live in the City limits)*
  • Are you interested in receiving information about our LGBT+ Programs?*
  • Are you interested in receiving information about our printed newsletter in the mail?*
  • Are you interested in receiving weekly emails about our Programs, Events and Happenings?*
  • Demographic Information:

    The below information helps the Senior Center apply for grants. Your input is appreciated!
  • Ethnicity:
  • Gender:
  • Gender:
  • Income Considerations: I receive
  • Caregiver Status: I have
  • Emergency Contact Information

  • Format: (000) 000-0000.
  • SASC Code of Conduct

    The following policies are in place to help ensure a safe, respectful, and enjoyable environment for everyone at SASC. Please take a moment to review this Code of Conduct, Liability Release, and Emergency Protocol, as participation in SASC programs indicates your understanding and agreement.

    Code of Conduct

    As a participant at the Sebastopol Area Senior Center (SASC), I agree to the following:

    • I will wear a shirt and shoes at all times while at SASC.
    • I will not wear soiled clothing or have an unpleasant body odor, including heavy perfume, or odors related to alcohol, marijuana, or cigarette smoke.
    • I will not deface, damage, or destroy any SASC property.
    • I will not leave or store personal belongings at SASC. I understand that SASC is not responsible for lost or stolen property and reserves the right to dispose of abandoned items.
    • I will not verbally attack, behave disrespectfully toward, or use loud, disruptive, obscene, hateful, or abusive language toward another individual.
    • I will not use racial or religious slurs or engage in sexual harassment.
    • I will not act in a disruptive, menacing, or physically threatening manner.
    • I will not appear at SASC under the influence of alcohol or recreational drugs.
    • I will not smoke, vape, or chew tobacco products while participating in any SASC program or event, whether on-site or off-site.
    • I will not remove SASC property without permission.
    • I will not use SASC facilities for conducting commercial business without a contract or memorandum of understanding with SASC.
    • I will not knowingly allow a non-registered person to actively participate in an activity.

    Violations and Disciplinary Process
    I understand that violations of this Code of Conduct may result in suspension and/or expulsion from a class, program, or from SASC entirely, without refund. If I fail to comply with staff direction, SASC may contact law enforcement for assistance.

    Liability Release
    In consideration of my participation in SASC activities, I agree to indemnify, defend, and hold harmless the Sebastopol Area Senior Center (SASC) and the City of Sebastopol, including their officers, employees, volunteers, instructors, and agents, from any and all claims, liabilities, damages, or causes of action arising out of or related to my participation in any SASC activity, including off-site programs and day trips. I understand and accept that SASC does not provide medical insurance coverage.

    Medical Acknowledgment and Release

    Duty to Self-Monitor

    I agree to self-monitor for signs and symptoms of communicable or infectious illness and will not attend SASC in person if I am experiencing symptoms of illness, including but not limited to flu, COVID-19, or other contagious conditions.

    Assumption of Risk

    I acknowledge and understand that:

    1. Participation in SASC activities includes possible exposure to and illness from infectious diseases, including but not limited to COVID-19. While preventative measures may reduce risk, serious illness or death may still occur.
    2. I knowingly and voluntarily assume all risks related to illness or infectious disease, even if arising from the negligence of the Released Parties.
    3. I knowingly assume the risk of injury, harm, or loss associated with participation, including those caused by the negligence or conduct of the Released Parties.
    4. Participation may involve health risks including, but not limited to, dizziness, lightheadedness, fainting, nausea, muscle cramps, musculoskeletal injury, sprains, strains, heart attack, stroke, or communicable illness. I agree to immediately discontinue participation and seek medical attention if I experience symptoms.
    5. I release the Released Parties from any claims arising from first aid, treatment, or services rendered in connection with my participation.

    Emergency Protocol & Medical Responsibility Acknowledgment

    I understand and acknowledge that SASC has the following emergency protocol:

    • SASC staff, volunteers, and instructors are required to call 911 in the event of a medical emergency, including but not limited to fainting, falls, severe bleeding, severe pain, shortness of breath, choking, chest pain, sudden weakness, confusion, difficulty speaking, or any condition that appears to require immediate medical attention.
    • SASC staff, volunteers, and instructors do not make medical judgments or diagnoses. Medical decisions are made by emergency responders or licensed medical professionals.
    • Once 911 is called, first responders will assess the situation and determine appropriate care, including whether transport to a medical facility is recommended.

    I further understand and agree that:

    • I am solely responsible for all medical expenses incurred as a result of an emergency, including but not limited to ambulance services (including non-transport or treat-and-release fees), hospital charges, medical treatment, and follow-up care.
    • SASC does not assume responsibility for payment of any medical or emergency service costs arising from an incident occurring on SASC premises or during SASC programs, activities, or events.
    • I agree to hold harmless and release SASC, its staff, volunteers, instructors, and agents from any liability related to emergency response actions taken in good faith.

    Disposition of Outstanding Funds
    In the event of my death, I authorize any remaining funds in my SASC account to be donated to SASC.

    Pet Policy
    Only trained service animals are permitted inside SASC facilities. If I bring a service animal, I understand that SASC may ask whether the animal is a service animal and what service the animal is trained to perform.

    Photo and Video Release
    I grant permission for SASC and its agents to photograph or video me during SASC programs or events and to use such images or recordings in SASC publications, website, social media, email communications, and other marketing or promotional materials.

    Acknowledgment

    I have read, understand, and agree to comply with SASC’s Code of Conduct, Liability Release, Medical Acknowledgment, Emergency Protocol, Pet Policy, and Photo/Video Release policies.

     

     

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