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City of Flagstaff Parks and Recreation Scholarship Application I am applying for the Scholarship Program, and I understand submission of the application, includes verification of City of Flagstaff residency, an approval letter from eligible subsidized services, and a State issued driver’s license or identification card and that if all information isn’t attached to the application it will not be reviewed. Name: Address: City: State: Zip: Phone: (home) (cell) Email: First and last name(s) and date of birth for eligible family members applying for the Scholarship Program: 1. 6. 2. 7. 3. 8. 4. 9. 5. 10. Please check the type of services you receive through the qualifying programs to be eligible for this program and the type of personal identification and proof of Flagstaff residency you are providing with this application: Cash Assistance (CA) AZ Driver’s License Nutrition Assistance Program (SNAP) City Utility Bill Health Insurance KidsCare Health Insurance Reduced-price school lunches I hereby certify that I am a City of Flagstaff resident, and all the above information is true and correct. I understand deliberate misrepresentation could result in permanent denial of eligibility in the Scholarship Program in the future. Signature of Applicant Date Revised: 4/30/22 Blue APPROVED stamp required to be valid: Approved by: Expiration Date (valid for 12 months) SIGN