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Athens-Clarke County Department of Leisure Services SCHOLARSHIP APPLICATION

Verification Stamp

PLEASE PRINT LEGIBLY Parent/Guardian(s) __________________________________________________________________________ Address _________________________________________City ________________State_____ Zip _________ Phone # _________________________________________ Cell # ____________________________________ Please list each child residing in the household in the box(es) provided below: Child’s Name

Child’s Birth date (mm/dd/yy)

% SCHOLARSHIP DISCOUNT (Department Use Only)

I certify that the information provided above is true and correct. Signature: _________________________________________________ Date: _____________________ (This application serves as a temporary scholarship card and will expire 45 days from the issue date. Your original card will arrive in the mail and cannot be picked up).

FOR DEPARTMENT USE ONLY Please check the documents used to verify the following. Attach copies of documents reviewed.

Dependents  Income Tax Return  CC School Dist. Person Summary Report  AHA Tenant Accounting Worksheet  Dept of Family & Children Svcs Document  Lease  Section 8 Document

Income  Income Tax Return  PeachCare/Medicaid/TANF*  Section 8 Document  Social Security/SSI Statement  Unemployment Document  Employment check stub

Residency  AHA Tenant Accounting Worksheet  Utility bill________________________  Lease  Section 8 Document  Local Agency Document____________  State Agency Document____________

 Local Agency Document______________  W-2 Statement  Federal Agency Document__________  State Agency Document ______________  CC School Dist. Person Summary Report  Federal Agency Document ____________ *PeachCare / Medicaid Card / TANF = 80% discount Staff Verification: ________________________________Issue Date: ____________________ Expiration Date:


Scholarship Form  

Any Athens-Clarke County resident under the age of 18 may apply for a scholarship. Documents used to determine the amount of a scholarship a...

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