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Revised 8-15-2012 Partial Scholarship Application Effective Date August 15, 2012 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 Scholarship recipients will receive one multiple pass good for 20 daily visits to the Recreation Center each recreation season (Winter/spring, Summer, and 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 50% of the activity registration fee, with the total award not to exceed $50. Scholarship may be applied for at any time. However, Activity Scholarship awards will be limited to a total amount not to exceed $150 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 cannot be transferred to another program and the amount of the scholarship awarded will be counted towards the $150 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 2 ≤$3,783 3 ≤$4,773 4 ≤$5,763 5 ≤$6,753 6 ≤$7,743 7 ≤$8,733 8 ≤$9,723 (307) 721-5269 FAX (307) 721-5284 TDD (307) 721-5295 CITY OF LARAMIE PARKS & RECREATION DEPARTMENT Recreation Division P.O. BOX C LARAMIE, WY 82073 ---PAGE BREAK--- Revised 8-15-2012 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