Rialto Community Services
Scholarship Application
Entry Date:_____/______/_____ Expiration Date:____/____/___ Office Use: Member#___________________
Receipt Number for activity enrollment:_______________________ Circle One: 01: Sports Program 02: Classes 03: Other Participant Information:
First Name:______________________ Middle:_________________ Last:________________________ Gender: M F Date of Birth:____/____/____ School:____________________ Grade:______________ Address:______________________________________________________________ Apt or Unit#:___________ City:__________________________ State:______ Zip:___________________ Phone:________________________ Email:___________________________________________________ Is this child eligible to receive free of reduced lunch at school? Yes No Please Check one: Multi-Racial Hispanic Caucasian/White Native American African-American Asian-American Other Primary Contact Secondary Contact
Name:_________________________________
Relationship:____________________________
Name:_________________________________
Relationship:____________________________
Emergency Contact: Authorized Pick up Emergency Contact: Authorized Pick up Works At:______________________________________ Works At:______________________________________ Cell Phone:_____________________________________ Cell Phone:_____________________________________ Home Phone:___________________________________ Home Phone:___________________________________ Work Phone:___________________________________ Work Phone:___________________________________ Email:_________________________________________ Email:_________________________________________ Office USE ONLY
Staff Name:_____________________________________________ Date:__________________________ Directors Approval:________________________________________________________
Annual Income (Check all that apply): $0-$10,000 $10,001-$20,000 $20,001-$30,000 $30,001-$40,000 $40,001-$50,000 $50,001-$60,000 $60,001-$70,000 $70,001-$80,000 $80,001-$90,000 $90,001+
Lives with (check all that apply): Mother Father Stepmother Stepfather Grandparents Foster Parents Guardian Other Rialto Community Services
Scholarship Application
Entry Date:_____/______/_____ Expiration Date:____/____/___ Office Use: Member#___________________
Receipt Number for enrollment:_______________________
Household Information
Head of Household: Male Female Single Parent: Yes No Number of People in household:___________________ Number of Children in Household: _________________ WAIVER: (to be completed and signed by parent/guardian if applicant is under 18 years of age.) I hereby consent for my child, named above, participating in the above activity, and I hereby execute the above agreement, waiver and release on their behalf. I state that said minor is physically able to participate in said activity. I hereby agree to indemnify and hold the City of Rialto Community Services Department, its officers, employees and agents free and harmless from any loss, liability, negligence, damage, cost or expense which they may incur and result in the death or any injury or property damage that said minor may sustain while participating in said activity. The City of Rialto reserves the right to photograph all program participants and use these photos in any issue of the City ’s recreation brochure or other City publications/marketing without the expressed written consent of the individuals. ______________ Parent/Guardian Initial
What size T-Shirt does your child wear?
Youth Size: Small Medium Large X-Large Adult Size: Small Medium Large X-Large Acknowledgement and disclaimer
I certify under penalty of Perjury that statements made on this form are true Name:_____________________________________________ Date:__________________________ Address:___________________________________________ Phone No:______________________ Parent/Legal Guardian Signature________________________________________________________