Child's Name:
Child's Date of Birth:
School Child Attends:
Parent's Name:
Address:
Phone Number:
Activity/Class:
Class ID:
Dates of Class:
Times of Class:
Activity Fee:
Amount you are able to pay:
Reason for scholarship request:
My child qualifies for free or reduced price meals
We have extenuating circumstances (please breifly explain below)
By printing my name below I am indicating that I understand school officials may use the information that I have provided to qualify for free or reduced meals to be considered to receive fee assistance for my child to attend this activity. I give up my rights to confidentiality only for the purpose of receiving fee assistance for the activity listed above.
Name:
Date:
Security Measure