Scholarship Application

Program Information

Application #*

Program, Class, or Activity Requested*

Please list specific dates, times, level & session of the program, class, or activity you are requesting*

Person Applying for Assistance

Last Name*

First Name*

Relationship to Child*

Address*

City*

Zip Code*

Email Address

Primary Phone*

Secondary Phone

Child/Participant Information

Last Name*

First Name*

Gender

FEMALE

MALE

Grade Level*

Age*

Date of Birth*

Ethnicity*

Primary Language Spoken in Home*

Have a pool, access to a pool, have a family member with a pool, infants/toddlers, children who have experienced a near drowning?*

YES

NO

Public Assistance

Currently Receiving Public Assistance*

YES

NO

Income Information

Note: If you answered "NO" to the question in the section "Public Assistance", fill out this section.

Total Household Monthly Gross Income

List All Children and/or Persons (Not Previously Listed) Currently in Household

Note: If you answered "NO" to the question in the section "Public Assistance", fill out this section.

How Many Additional Persons in Household?

Last Name (1)

First Name (1)

Relationship to Child (1)

Age (1)

Last Name (2)

First Name (2)

Relationship to Child (2)

Age (2)

Last Name (3)

First Name (3)

Relationship to Child (3)

Age (3)

Last Name (4)

First Name (4)

Relationship to Child (4)

Age (4)

Last Name (5)

First Name (5)

Relationship to Child (5)

Age (5)

Acknowledgement

Signature*

Date*

I Verify That the Information Given Is Complete and Accurate. I Understand That All Information Provided Is Confidential. Documentation Will Be Required Prior To Enrollment.

Filing of this application does not guarantee scholarship award or approval nor does it reserve spaces within a program, class, activity or event. You are responsible for payment of tuition fees in excess of the amount awarded to be enrolled in a program. Furthermore, I understand this scholarship is solely for the purpose of participating within a Jurupa Area Recreation and Park District program, class, activity or event and that the funds will be transferred to the program if the scholarship is awarded.