Forms must be filled out and returned by Feb 1st for Summer Camp 2016
Please fill out and email/turn in to Sara Alvarez-Torre @ alavarez-torres@ci.eustis.fl.us
City of Eustis Parks & Recreation
Scholarship Application 2016
Participant Information Form
(Please fill out one form per child)
Participant Information
First Name:____________________________ Last Name:__________________________________
Birth date: _____________________________ Age:__________ Gender: ________________
School: _________________________________
Street Address:______________________________ City: _______________ Zip Code:_________
Mailing Address: ____________________________ City: _______________ Zip Code:________
Check one to indicate if your child is currently receiving
_________ Free or _________ Reduced lunch at school.
Legal Guardian Information
Fathers Name: ______________________________ Home Phone: _________________________
Cell Phone: ______________________________
Mothers Name: _____________________________ Home Phone:__________________________
Cell Phone: ______________________________
Fathers Email: ___________________________ Mothers Email: __________________________
Guardians Work Information
Do you work for the City of Eustis? ________ yes ________ no
If yes, please state job and department: ____________________________________________
State names of relatives and friends working for the City of Eustis:______________ __________________________________________________________________________________________
CITY of EUSTIS PARKS & RECREATION
2214 E. BATES AVE. EUSTIS, FL 32726
(352)357-8510
The City of Eustis would like to provide families in the community with an opportunity to experience our services. The City of Eustis has an extremely limited amount of scholarships available. It is our desire that no child be denied access to our programs due to financial difficulties. However, there is a limited amount of scholarship money available. These scholarships will be awarded to those most in need. Please complete the following information accurately and completely.
ELIGIBILITY:
1. Assistance is granted upon applicants City of Eustis residency.
2. Assistance is based on the basis of financial need. (We consider household income and number of dependents as primary criteria).
3. The scholarship Program Application must be completed entirely, along with a letter written by you stating why you are requesting a scholarship in order for the applicant to be considered.
4. SCHOLARSHIPS ARE NOT GUARANTEED ON AN ON-GOING BASIS. It is necessary for each recipient to reapply before signing up for another program. Scholarships are granted by program.
5. Please allow at least 30 days for processing, each time you apply.
6. Scholarships are allowed one time per family a year (January-December).
HOW TO APPLY:
1. Fill out one registration form and one Scholarship application form per child.
2. Applicants must complete all sections of the Scholarship Application. Please do not leave any spaces blank. Documentation from all income sources must be provided.
3. The following MUST be included with the application:
Two City of Eustis water bills to determine residency.
Proof of income/two most recent paycheck stubs showing income for each adult in household.
Photocopy of drivers license
Other documents showing proof of income from other sources:
Social Security benefit statement
Free and reduce lunch statements
Unemployment benefit statements
4. All information contained in the Scholarship Application will remain confidential.
5. Financial assistance eligibility will be based on review of your information. The City of Eustis reserves the right to deny assistance to any applicant.
6. Incomplete applications cannot be processed and will be returned to the applicant for completion.
PROCESSING:
Financial assistance eligibility will be determined by our Administration Staff based on review of the applicants information.
You will be notified by mail whether or not you have been selected or denied a scholarship.
City of Eustis Parks & Recreation
Scholarship Application 2015
Income Information Form
(Fill out one form per family)
Part 1 All households must complete the following. If you are currently receiving Food Stamps you must list a current case number for each child.
Childs Name School Date of Birth Food Stamp #
1.
2.
3.
4.
5.
Part 2 Household members and monthly income:
(1) Write the names of all persons in your household, whether they receive income or not. Include yourself, the children you are applying for, all other children, your spouse and any related or unrelated people in your household. Use another piece of paper if you need more space.
(2) Write the amount of monthly income each household member made last month, before taxes or anything else is taken out, listing it in the column that shows where it came from. Please refer to the INCOME THAT MUST BE REPORTED chart below. Pay stubs for the last two pay periods must be included in this application for each person listed working.
Names
Monthly Income
List the names, ages & relationship of everyone in your household. Gross monthly earnings before deductions Monthly Welfare, Child Support or Alimony Monthly Pensions, Retirement or Social Security
Income that must be reported:
Wages, salaries, tips, unemployment compensation, workers compensation, income from self owned business, pensions, SSI, veterans payments, retirement income, social security, public assistance, welfare, alimony, child support.
I certify that all of the above information is true and correct and that all income is reported. I understand that this information is being given for the receipt of a scholarship. That the City of Eustis may verify the information on the application and that deliberate misrepresentation will cause me to lose any scholarship.
Signature:______________________________ Print Name:_________________________________
Home phone:_____________________ Work phone:_____________________ Date:_____________
