Please read more about the [Youth Scholarship Program] PDF-FILE

Youth Scholarships Form

*Required Fields

*Last Name:

*First Name:

* Day Phone:

*Cell:

*E-mail Address:

* Address:
(No P.O. Box)

*City:

*State:

*Zipcode:

*Employer:

*Telephone:

NUMBER IN HOUSEHOLD:

*Adults:

*Children:

TOTAL ANNUAL HOUSEHOLD INCOME:

12 MONTH DATE RANGE OF HOUSEHOLD INCOME:

*From:
mm/yyyy

*To:
mm/yyyy

*At which recreation center will you participate most often?

Please list all youth family members that will be requesting this Scholarship

	Last Name	First Name	Date Of Birth (mm/dd/yyyy)	Relationship
1.
2.
3.
4.
5.

Please complete the following information. This should include all persons related by blood, marriage, or adoption residing in the household. Please list employers or other sources of income. (For example, income received from Social Security, retirement benefits, or child support payments.)

	Adult Name	Employer	Employer Phone	Annual Income
1.
2.
3.
4.
5.

The City of El Paso reserves the right to revoke a Youth Scholarship offered to an individual. All scholarship recipients are expected to abide by all rules and regulations of the program and to treat park and recreation facilities with proper respect.

Applicants who provide incorrect, incomplete or false eligibility information to the City will not be eligible for scholarship.

I certify that all the information provided on this application is true and correct to the best of my knowledge and that all previous year household income is reported. I authorize that information on this document may be verified with the employers or other income sources, and authorize said employers or other sources to release this information. By typing in your name and dating this electronic form, you are certifying that the information contained herein is truthful.

*Adult Signature:

*Date:

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