Get Out & Play and ACTiV8 Partial Scholarship Application GOAP & ACTiV8 Partial Scholarship Application Student Info If you qualify for the free and reduced lunch program you do not need to fill out this form, please use the scholarship ticket embedded in the programStudent 1 - Name* First Last Birth Date* MM slash DD slash YYYY Grade*123456789School*Daniels Canyon ElementaryEcker HillHeber Valley ElementaryHomeschoolJeremy RanchJR Smith ElementaryMcPolinMidway ElementaryOld Mill ElementaryParleysPark City Day SchoolRocky Mountain Middle SchoolSilver Summit Elementary SchoolSilver Summit Middle SchoolSouth Summit Elementary SchoolSouth Summit Middle SchoolTimpanogos Middle SchoolTrailsideTreasure MountainWasatch Learning AcademyWeilenmannStudent 2 - Name First Last Birth Date MM slash DD slash YYYY Grade123456789SchoolEcker HillHeber Valley Elementary SchoolHomeschoolJeremy RanchMcPolinParleysPark City Day SchoolRocky Mountain Middle SchoolSilver Summit Elementary SchoolSilver Summit Middle SchoolSouth Summit Elementary SchoolSouth Summit Middle SchoolTrailsideTreasure MountainWeilenmannStudent 3 - Name First Last Birth Date MM slash DD slash YYYY Grade123456789SchoolEcker HillHeber Valley Elementary SchoolHomeschoolJeremy RanchMcPolinParleysPark City Day SchoolRocky Mountain Middle SchoolSilver Summit Elementary SchoolSilver Summit Middle SchoolSouth Summit Elementary SchoolSouth Summit Middle SchoolTrailsideTreasure MountainWeilenmannParent InfoParent/ Guardian Name* Relationship to Student* Mother Father Legal Guardian Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Phone*Annual Household Income* $50,000-$55,000 $55,001-$60,000 $60,001-$65,000 $65,001-$70,000 $70,001-$75,000 $75,001-$80,000 $80,001-$85,000 $85,001-$90,000 $90,001-$95,000 $95,001-$100,000 $100,001-$120,000 Please note that if you earn above $120,000 you do not qualify. (You may be asked to provide proof of income in the form of paystubs, tax forms, or W-2's):Total Household Members Under Age 18* 1 2 3 4 5 6+ Total Household Members Age 18+* 1 2 3+ Please provide information why you are seeking a partial scholarship or extenuating circumstances that require a scholarship.*Please describe in detail, we may need more information for approval.Have you received a YSA scholarship in the past?* Yes No What programs are you applying for?*What would your child be doing without this scholarship?* Scholarship Agreement* I agree my child will fully participate in all sessions of the program and I will pay the commitment fee in full If my child/children receives a partial scholarship from the Youth Sports Alliance, by checking this box, I agree to the following: (1) I will pay the commitment fee in full; (2) My child will fully participate in the program. If my child does not attend the lessons regularly, I understand that we will not be eligible for a scholarship the following year.Terms & Conditions If my child(ren) is awarded a Partial Scholarship, I understand that: • My child(ren) must arrive on time and stay for the duration of each day of the program. In the event my child(ren) are frequently late or missing, they may be withdrawn from the program and attendance records will be considered as part of any future scholarship application. • My child(ren) will be required to write two (2) thank you notes to the Youth Sports Alliance sponsors which must be submitted by the final day of the program session. * Check this box to indicate that you have read and agree to the terms stated above. Δ
