What Parks and Community Services Department program are you requesting funding for? Please indicate Activity Number and Name of Class. Activity Number Class Name Fee for Class Start Date of Activity
Amount of funding requested $
Participant’s Name: Age:
Address:
Primary Parent/Guardian Name:
Primary Phone: Secondary Phone:
Email:
Family Size:
Proof of one of the following programs (please check box(s) that apply): Medicaid WIC (Women, Infants, and Children) Free/Reduced Price School Meals Foster Care Participant Native American Tribe
Has your child received San Ramon Parks & Community Services scholarship funding before? Yes No If Yes, When: Amount $
Comments or additional information you wish to add:
I certify that all statements on this application are true and correct. I understand that false or incorrect statements shall be sufficient cause for disqualification of request.
Signatur​e