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2. 
4. 2023 Parks and Recreation Scholarship Application

   Fill out completely and list everyone currently living in your household.

6. Adult #1 First Name*
7. Last Name*
9. Address*
11. City*
12. State*
13. Zip Code*
15. Primary Phone Number*
16. Secondary Phone Number
18. Email Address
20. Birthdate*
21. Gender*
23. Emergency Contact Info*

    Name, Relationship, and Phone number

25. There is a second adult in my household*

    1. Yes
    2. No
27. Adult #2 First Name*
28. Last Name*
30. Birthdate*
31. Gender*
33. Primary Phone Number*
34. Secondary Phone Number
36. Email Address
38. I have children in my household*

    1. Yes
    2. No
40. How many children do you have in your household?*

    1. 1
    2. 2
    3. 3
    4. 4
    5. 5
    6. 6
42. Child # 1 First Name*
43. Last Name*
45. Birthdate*
46. Gender*
48. Child #2 First Name*
49. Last Name*
51. Birthdate*
52. Gender*
54. Child #3 First Name*
55. Last Name*
57. Birthdate*
58. Gender*
60. Child #4 First Name*
61. Last Name*
63. Birthdate*
64. Gender*
66. Child # 5 First Name*
67. Last Name*
69. Birthdate*
70. Gender*
72. Child # 6 First Name*
73. Last Name*
75. Birthdate*
76. Gender*
78. 1. Do you qualify for the free or reduced lunch program?*

    1. Yes. If yes, please provide a letter from the school's Nutrition Office stating free or reduced.
    2. No. If you do not have a letter from your school, we will accept a copy of your 2022 tax form 1040/1040A.
80. Upload letter/Tax Form 1040/1040A*
82. 2. Within the last 10 months has there been any financial hardship for your family?*

    1. Yes
    2. No
84. Please explain*
86. A copy of the school nutrition letter or tax form must be turned in with this form.
88. I verify that all the above listed information is 100% accurate. If any information is found incorrect, I understand my registration/membership will be withdrawn and my payment will be forfeited.
90. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
92. Electronic Signature*
93. Today's Date*
    Today's Date
Leave This Blank:


96. 1. Receive an email copy of this form.
97. Email address

    This field is not part of the form submission.

98. Submit

* indicates a required field