Folsom Athletic
Association
916-989-4752
Application for Summer
Kempton
Youth Assistance Soccer Scholarship
APPLICANT
Name:
________________________________________________ Birthdate: _________________
Address:______________________________________ City: ________________ State: ________
Home Phone:
_________________________ School:
____________________________________
Grade: _______________ Teacher: ________________________________________
Has applicant participated
in Folsom Recreation programs before?
Yes £ No £
If yes, what and when?
_____________________________________________________________
Please list applicable
hobbies, interests and outside activities, if any: __________________________
________________________________________________________________________________
PARENT / GUARDIAN
Name:
_____________________________________________ Home Phone: _________________
Address:
_____________________________________
City: ________________
State: ________
Marital Status: Single £ Living
as a couple £
Number of children in
household: __________ Occupation: ________________________________
Occupation of other wage
earners in household: _________________________________________
If unemployed, source of
income: _____________________________________________________
How will your child get to
and from Folsom Recreation activities? ____________________________
ACTIVITY
Youth
Soccer
Folsom Athletic
Association
916-989-4752
Application for Summer
Kempton Youth Assistance Soccer Scholarship
REFERENCES (examples include clergy, social worker, doctor, other
non-family members)
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Name |
Relationship |
Phone |
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ADDITIONAL INFORMATION
If there is any additional information you would like to
provide, for example a participantÕs statement, extenuating circumstances,
volunteering ability, etc. that would assist us in determining whether the
assistance will be awarded, please use the space provided below, or attach
additional sheets, as necessary.
AGREEMENT
The facts set forth in this application are true and
complete. I understand that false
statements on this application shall be considered sufficient cause for
disqualification from funding assistance.
The Folsom Athletic Association and the Folsom Recreation Division Youth
Assistance Fund Committee are hereby authorized to research my qualifications
for funding assistance by contacting references, teachers and other pertinent
individuals. I understand that I will
be contacted if I am accepted for assistance, and that assistance may be either
a full or partial scholarship
Signature
of Applicant Date Signature
of Parent / Guardian Date
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Application Received |
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Office Use Only |
Activity |
ParentÕs Fee |
FAAÕs Fee |
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Recommendations |
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