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2. Applicant's First Name: (One person per application)*
3. Applicant's Last Name*
5. Parent/Guardian Name(s)*
6. Applicant's Age:*
8. Address*
10. City*
11. State*
12. Zip*
14. Phone Number*
15. Email Address
17. Size of Family*
21. Please list your activity choice in which you are applying for a scholarship
23. 3 Month Pass or Punch Card

    1. Rec Center Individual Pass
    2. Rec Center Family Pass
    3. Rec Center Punch Card

    1. Miller Activity Complex Individual Pass
    2. Miller Activity Complex Family Pass
    3. Miller Activity Complex Punch Card
25. OR
27. Activity Name:
28. First Choice:
29. Second Choice:
31. Activity Number:
32. First Choice:
33. Second Choice:
35. Session Dates:
36. First Choice:
37. Second Choice:
39. Activity Price:
40. First Choice:
41. Second Choice:
45. How will you benefit from the requested recreation activity?
47. Please indicate which of the following state and federal assistance programs that you presently participate in: (supporting documentation must be attached)

    1. Aid to Families with Dependent Children (AFDC)
    2. Supplemental Security Income (SSI)
    3. Supplemental Security Disability Insurance (SSDI)
    4. Reduced Lunch Program/Free Lunch Program
    5. Subsidized Housing (HUD)
    6. Food Stamps
    7. Other (Please provide any other information that would further explain your financial situation)
49. Household annual income: $
50. Rent/Mortgage Amount:*
51. Attachments:
53. *Previous year Income Tax return MUST be submitted with application. Letter of reference (i.e. from a teacher, neighbor, doctor etc) are optional and may be attached. All applicants are welcome to submit with this application any additional information that would pertain to being considered for scholarship assistance.
55. I certify that to the best of my knowledge the information I have provided is true.

    1. Accept
57. Applicant/Guardian Name:
58. Date:
    Date:
60. *Efforts are made to keep confidential all information concerning applicants and recipients.
    
    RETURN TO:
    
    Scholarship Coordinator Castle Rock Community Recreation Center 2301 N. Woodlands Boulevard Castle Rock, CO 80104
    
    DEADLINES: JAN. 15, MAY 15 and/or SEPT. 15
    
    Application must be filled out completely and all necessary documentation attached and ON TIME to be considered for a scholarship. All applications received after deadline will be considered in the following session.
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62. 1. Receive an email copy of this form.
63. Email address

    This field is not part of the form submission.

64. Submit Submit and Print

* indicates a required field