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Financial Assistance Confidential Application Form

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:

Place of Employment: 

Family Size: 

Names of entire Household:
Name:   Age (if under 18): 
Relationship to Applicant 
Name:   Age (if under 18): 
Relationship to Applicant 
Name:   Age (if under 18): 
Relationship to Applicant 
Name:   Age (if under 18): 
Relationship to Applicant 
Name:   Age (if under 18): 
Relationship to Applicant 
Name:   Age (if under 18): 
Relationship to Applicant 

Proof of one of the following programs (please check box(s) that apply):
 Medicaid
 WIC (Women, Infants, and Children)
 Free/Reduced Price School Meals

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 



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