Athens-Clarke County Department of Leisure Services SCHOLARSHIP APPLICATION
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:
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...