* Required fields
Name *
E-mail Address *
Scholarship Requested for What Program or Pass; *
Which program and fee are you inquiring about? (Example: Swim Lessons $45) *
What do you think you can pay? *
State the special need which makes it impossible for you to pay the entire fee: *
Participant's Name: *
Address: *
City: *
Zip *
This scholarship will be used for: *
Start Date: *
Number of Children Living At Home: *
Number of Adults in Household: *
Phone Number: *
(If Under 18) Father's Name:
Father's Employer
(If Under 18) Mother's Name:
Mother's Employer
Total Yearly Family Income (Include Child Support if Applicable) *	$0 to $17,224 $17,225 to $23,107 $23,108 to $28,990 $28,991 to $34,873 $34,873 to $40,756 $40,757 to $46,639 $46,640 to $52,522 $52,523 to $58,405
	Check if Applicant/Participant Qualifies for Federal Free or Reduced Lunch Program
	Check if Applicant/Participant Qualifies for Oregon Health Plan
Participant / Parent / Guardian Digital Signature- I am signing my name that all of the above information is true and correct: *

I have read and agree to the Privacy Policy *

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NOTE: When applying for a second scholarship for an individual within a calendar year, Astoria Parks and Recreation requires a copy of your latest 1040 Income Tax form or other accepted form to verify your income.  This information must be updated with the subsequent scholarship request.  Please email this information to info@astoriaparks.com