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Revised 5-11-11 Laramie Parks and Recreation Partial Scholarship Application Effective Date June 1, 2011 General Scholarship Guidelines - If you have any questions please call [PHONE REDACTED] Awarded to children, youth, adults, and seniors under the approved scholarship guidelines. Scholarship considerations are based on family income/financial need, family size, and highly extenuating circumstances. Proof of this information (copies of prior year W-2 forms, payroll check stubs, college financial award letter, loans, child support, grants, alimony, birth certificates, and other relevant documentation) will be required as proof of the above-mentioned information. All information will be kept strictly confidential. Completing an application is not an automatic assurance of a scholarship award. All scholarship applications must be delivered to the Parks & Recreation office, PO Box C, Laramie, WY 82073. Income guidelines are based on the Wyoming Department of Family Services guidelines and are listed below. Recreation Center Multi-Pass Scholarship Guidelines Each Scholarship recipient may receive one multiple pass good for 20 daily visits to the Recreation Center each recreation season Winter/spring, 1- Summer, and 1- Fall). Scholarship recipients must pay 30% of the applicable multiple pass fee for their age group. Activity Scholarship Guidelines All recreation activity scholarships are partial awards, covering up to 50% of the activity registration fee, with each individual award not to exceed $50. Scholarships may be applied for at any time. However, Activity Scholarship awards will be limited to a total amount not to exceed of $150.00 per any twelve (12) month period of time per individual. If a scholarship recipient finds that they are unable to attend the registered activity, it is the recipient’s responsibility to notify Parks & Recreation staff to cancel at least 3 working days prior to the start date of the activity. If a scholarship recipient cancels an awarded class, the scholarship can not be transferred to another program and the amount of the scholarship awarded will be counted towards the $150.00 maximum allowed in a twelve (12) month period. Refund of the fee portion paid by the scholarship recipient will be processed and refunded within 3 weeks of notification. Household Size Income Eligibility for Scholarship Awards Annual / / Weekly 2 $44,136 / $3,678 / $ 849 3 $55,584 / $4,632 / $1,069 4 $67,056 / $5,588 / $1,290 5 $78,516 / $6,543 / $1,510 6 $89,964 / $7,497 / $1,846 7 $101,436 / $8,453 / $1,951 8 $112,896 / $9,408 / $2,171 ---PAGE BREAK--- Revised 5-11-11 I. Family Information Please list all household members living in the home, and the activity number(s) for which this scholarship application applies. (Please note “Multi-Pass” for activity number if applicable.) All Household Member Names Age Activity Name & Number or Pass Type II. Income Please list previous year total annual or income reported on payroll check-stub, W-2 forms, college grant, scholarship, loan information; and any other income and attach proof of income. (Without proof of income attached, your application cannot be processed.) (Requires verification by 2 staff members if proof of income is not kept on file. / ) III. Additional Information Please provide any other information that would be helpful in considering this application. Applicant Signature: Date: Address: Phone Fees Paid: Multi-Pass or Class Name: Date: For Internal use only: Class Name or Multi-Pass Scholarship Award Decision Approved (initial) Date Denied* (initial) Date Date of notification of Approval/Denial Applications will be destroyed 30 days after notification of approval if incomplete or payment is not received. Amount Due: *Reason for