Park Township

Scholarship Application

(To be completed by Parent or Guardian)

First Name ______________ Last Name ____________________________________________

Address ________________ City ________________ Zip __________ Twp. ______________

Phone: (day) _____________ (evening) ______________ E-mail _________________________

List all immediate family members in your household below. Immediate family members include only parents and children. This does NOT INCLUDE grandparents, grandchildren, cousins, aunts, uncles, etc…..

Number in family residing at above address: __________________

Name

Birth Date (month/year)

Name

Birth Date(month/year)

Financial Information

TOTAL FAMILY INCOME BEFORE DEDUCTIONS (includes wages of all working family members, welfare payments, pension, social security, scholarships and regular contributions not living in household).

You MUST include documentation for all household income (Example: Income Tax Returns, W2 Forms, DSS Form, SSI Form, Social Security or Unemployment Annual Statements.)

Please list Financial Assistance, if any, from any of the following:

Source of Income	Monthly Income	Source of Income	Monthly Income
Your Employment	$	Workers Compensation	$
Other Family Employment	$	Social Security	$
Unemployment	$	Pension	$
Family Independence Agency	$	Other (explain source):	$
Child Support/Friend of the Courts	$	TOTAL MONTLY INCOME	$

Reduced Fee Discount Table

Scholarships are figured on a sliding scale as based upon the Standard Federal Income Guidelines.

By signing below I give permission to authorize the Park Township Recreation Department to contact employers, social agencies, etc…to verify information on this application. I also understand that deliberate misrepresentation of information subjects the applicant to being disqualified for scholarship consideration. I hereby certify that all of the above information is true and correct to the best of my knowledge and belief.

Applicant Signature ___________________________ Date ________________

Internal Use Only

Approved % of Reduction for Scholarship _________ By: ____________ Date____________

Park Township Recreation Department Scholarship Information

What is a scholarship?

A scholarship is a reduced rate or fee assistance for Park Township Recreation Department Programs and activities based on a financial need. Program fees maybe discounted 25% or 50% or 75%. All applicant’s personal financial information is kept confidential. Class instructors and program leaders are not informed of participant’s scholarship status.

Scholarships apply to most programs or activities with the exception of:

· Facility Rental Fees

· Late Fees

· Adult Athletic Team/Or Player Fees

· Program Fees Of $10.00 Or Less

How to apply for reduced fees?

1. Simply complete the Park Township Recreation Department Scholarship Application Form.

2. Attach supportive documentation to substantiate annual income. Staff can not approve scholarship application without proper documentation.

3. Fax, mail or drop off all information to:

Park Township

52-152^nd Avenue

Holland, MI 49424

Phone (616) 738-4233 * Fax (616) 399-8540 * Email bburmeister@parktownship.org

4. Applicants will be notified within 3 business days regarding their reduced fee status.

5. The scholarship applicant is responsive to register for the desired program or activity. Scholarship application and/or approval is separate from registration. Once approved, the reduced program fee must be paid and registration completed in order to participate in any class, activity or program. Classes or programs that are full or cancelled may not be available regardless of scholarship status. The scholarship application will not hold a reservation for any class, activity or program with limited registration spots. The registration is not completed until after the scholarship is approved and the balance is paid in full. The scholarship application must be completed at least three business days before the deadline, in order to insure that the applicant may have a change to pay the balance in full, which must be done before the deadline.

Who can receive a scholarship?

Scholarships are available to Park Township residents ONLY! Discounts are based on the number of immediate family members in the household and their combined income from all sources.

· Income is calculated on gross income (before deductions from taxes, insurance premiums, union dues, bond, employee’s social security taxes and other employee deductions). Income includes net income form self-employment, social security, public assistance, alimony, child support payments, regular contributions from people not living in the same household, monetary compensation for services such as wages, salary, commission for fees and other cash income.

· The Park Township Recreation Department may consider both the income of the family during the previous calendar year and the family’s current income to determine which is the better indicator or need for a scholarship.

Any further questions can be answered by calling the Park Township Recreation Department at (616) 738-4233.

Park Township Recreation Department’s Scholarship Sliding Scale

Scholarships are figured on a sliding scale as indicated in the table below.

Annual Income	Single Individual	Two Member Household	Three Member Household	Four Member Household	Five Member Household
$0-$10,900	75%	75%	75%	75%	75%
$10,901-$14,600	50%	75%	75%	75%	75%
$14,601-$15,540	50%	50%	75%	75%	75%
$15,401-$18,400	25%	50%	75%	75%	75%
$18,401-$20,800	0%	50%	50%	75%	75%
$20,801-$22,200	0%	25%	50%	75%	75%
$22,201-$26,000	0%	0%	50%	50%	75%
$26,601-$29,700	0%	0%	25%	50%	50%
$29,701-$31,500	0%	0%	0%	50%	50%
$31,501-$33,500	0%	0%	0%	25%	50%
$33,501-$37,000	0%	0%	0%	0%	50%
$37,001-$42,300	0%	0%	0%	0%	25%
$42,301-$47,600	0%	0%	0%	0%	0%

**Source: This table is based upon Standard Federal Income Guidelines