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You must attach paperwork which validates your income, i.e. 1040 tax form from the most recent year (plus current pay stub and child support income) or TANF/SSI Statement (no additional pay stub is required). If you have a complete lack of income, no address or other special circumstance, please describe your situation on a separate piece of paper. Everybody Plays Recreation Scholarship Application Head of household requesting assistance: Name: Other parent or guardian: Please allow up to one week for processing Date: Name: Address: City/Zip: Phone: (home) (work) (cell) Email: Total household annual gross income (INCLUDE CHILD SUPPORT) Number of people in household: Are you employed? Employer: Are you employed? (other parent or guardian) Employer(other parent or guardian): Are you NOT willing to be photographed or interviewed in support of the Everybody Plays! program? If so, initial here: Please fill in all the information below for each household member even if they will not be registering for a class this term. If you need more space, please attach an additional sheet. Additional Family Members Phone Birth Date Age M/F I hereby agree to release, save and hold harmless the City of Woodburn and their respective officials, administrators, employees, volunteers and agents from any and all liability and claims for any damage or injury brought by me, my family, estate, heirs, or assigns arising out of my enrollment or participation in this program except as may arise solely from the gross negligence of the City of Woodburn or from the acts of third parties. My signature below signifies that I voluntarily agree to all the terms and conditions contained herein. I certify that all of the information provided on this form is true and correct and that all income is reported. I understand that this information is being given for the receipt of Recreation Scholarship assistance; that City officials may verify the information on the ap- plication; and that deliberate misrepresentation of the information may subject me to prosecution under applicable laws. Signature: Date Approved Logged Date Scholarship % Assistance Needed Call: Woodburn Aquatics Center 190 Oak St. [PHONE REDACTED] City Hall 270 Montgomery St. [PHONE REDACTED] Please Return completed application to: Woodburn Aquatic Center Attn: Scholarship 190 Oak St, Woodburn, OR 97071