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Financial Assistance Confidential Application Form

What Parks and Community Services Department program are you requesting funding for? Please indicate Activity Number and Name of Class.
Activity Number   Class Name 
Fee for Class       Start Date of Activity 

Amount of funding requested $ 

Participant’s Name:   Age: 


Primary Parent/Guardian Name: 

Primary Phone:  Secondary Phone: 



Family Size: 


Proof of one of the following programs (please check box(s) that apply):
 WIC (Women, Infants, and Children)
 Free/Reduced Price School Meals
 Foster Care Participant
 Native American Tribe

Has your child received San Ramon Parks & Community Services scholarship funding before?     Yes   No
If Yes, When:     Amount $ 

Comments or additional information you wish to add:


I certify that all statements on this application are true and correct. I understand that false or incorrect statements shall be sufficient cause for disqualification of request.


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