Fillable Hickory Parks, Recreation & Sports Tourism Department Bill (City of Hickory)

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Hickory Parks, Recreation & Sports Tourism Department Bill (City of Hickory)

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The Hickory Parks, Recreation & Sports Tourism Department Bill (City of Hickory) form is 2 pages long and contains:

  • 1 signature
  • 5 check-boxes
  • 60 other fields

Country of origin: US
File type: PDF

U.S.A. forms for City of Hickory

BROWSE CITY OF HICKORY (NC) FORMS

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Hickory Parks, Recreation & Sports
Tourism Department Bill McDonald
Scholarship Fund Application
Application must be completed by parent or legal guardian. Recipient must be a City of Hickory resident.
Parent/Guardian First Name: MI: Last Name:
Current Address: Email:
Must be a resident of Hickory, NC Zip Code:
Home Phone: Cell Phone: Work Phone:
Have you or another household member previously requested fee assistance from a Hickory Parks & Recreation Program? Yes □ No □
If so, when? ________________________________________ What assistance was provided? _____________________________________
Number of Adults in Household: Number of Children under 18 in Household:
Participant 1’s Name: Date of Birth: Grade:
Program: Dates: Day/Time: Fee:
Program: Dates: Day/Time: Fee:
Equipment Needs: Fee:
Participant 2’s Name: Date of Birth: Grade:
Program: Dates: Day/Time: Fee:
Program: Dates: Day/Time: Fee:
Equipment Needs: Fee:
Do you currently receive free or reduced food
assistance at your school?
Select one: YES
NO
(if no, complete income
section on next page)
□ If yes, attach letter of proof of food assistance program
required from school
Total
Monthly Household Income $ □ Proof of Iden<ty (Photo ID)
Utilities Expenses $ □ Proof of Residence within City of Hickory City limits
Rent/Mortgage $ □ Birth Cer<ficate of Child(ren)
Car Payments $ □ Proof of Income; i.e. Tax return from previous year,
current paystubs
Daycare Expense $
Other Monthly Expenses:
Please state why you are unable to afford the fee(s) for the program(s): Please use additional paper if necessary.
PLEASE NOTE THE FOLLOWING:
By signing below, you give your permission for this request to be processed by Hickory Parks, Recreation & Sports Tourism Department to determine
your eligibility for fee assistance. HPRSTD will complete a financial needs assessment on applicants and determine eligibility for a scholarship or payment
plan. Applicant is responsible for actual program enrollment.
All information on this application will be treated as confidential and used only to determine your eligibility for the fee assistance program. Your
signature indicates that all information provided on this application is true and complete, to the best of your knowledge. You understand that providing
false or incomplete information will result in this and any future applications being denied. If you are offered fee assistance and decide not to participate
in the program, you agree to abide by Hickory Parks, Recreation & Sports Tourism Department procedures for program withdrawal and you understand
that non-attendance or failure to pay your agreed-upon portion under any payment arrangement outlined below may make you ineligible for future
consideration for fee assistance.
Signature (Parent/Guardian if under 18)
Date
What Happens Next? You will be contacted by a Hickory Parks, Recreation & Sports Tourism representative to let you know if your request
has been approved.
This section is to be completed by Scholarship Committee
Fee Arrangement/Payment Plan Recommendation
Recommendation Total Award Amount ($) BMSF Total Balance Due ($) from Applicants
no later than the first day of the
program
□ Full Scholarship
□ Par<al Scholarship
□ I understand and agree to the payment plan as outline above. Applicant Initials: _______
□ I hereby give my permission for Hickory Parks, Recrea<on & Sports Tourism to share anonymous details of my story for purposes of
promo<ng this scholarship program. (You are not required to give this permission.) Applicant Initials:
Hickory Parks, Recreation & Sports Tourism Department Representative Signature:
Date:
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Hickory Parks, Recreation & Sports Tourism Department Bill (City of Hickory)

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Completed 17 February 2021

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