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APPENDIX “E” – Financial Assistance Application DOUGLAS COUNTY SCHOLARSHIP APPLICATION FINANCIAL ASSISTANCE PROGRAM

Parents/Guardian Name (please print) _______________________________________________________ Address: ______________________________________________________________________________ City: __________________________ County: _________________________ State_____ Zip _________ Home Phone Number: ________________________ Alternate Phone Number: ______________________ Name and ages of children for whom the request is being filed: 1. ________________________________________ 2. ___________________________________ 3. ________________________________________ 4. ____________________________________ If your family qualifies for any of the following programs, please list your program or client number: DFACS (Department of Family and Children Services # _______________________________________ FOOD STAMPS # ____________________________ COUNTY: _______________________________ FREE LUNCH # _____________________________ SCHOOL NAME: _________________________ I am unable to pay registration fees at this time due to the following circumstances: __________________ ______________________________________________________________________________________ Completion of this form does not guarantee a free scholarship, but is simply an application for consideration. If rejected, I accept on behalf of my child/children, one or more of the following financial options in order for my child to participate in the recreational program at said park. I will comply with the decision of said park. In-county children only will be considered for a free scholarship. ________ 1. Free ________ 2. Reduced Payment Fee – ½ of current registration fee plus the County Impact Fee $10.00. ________ 3. Payment Plan (current registration fee including County Impact Fees paid in four equal installments within 30 days of opening day of regular season). The above information is accurate. I authorize the park to verify said information for the purpose of processing this form. I understand all information will remain confidential. Parent/Guardian Signature: ___________________________________ Date: ___________________ FOR PARK USE ONLY: Circle Applicable Season: Spring Fall Park Location: ___________________________________________

Approved __________ Rejected __________ Option: 1 or 2 or 3 (circle one) Park Representative Signature: ______________________________________