Request For Financial Assistance
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1Date Applied:_______________
LAKELAND YOUTH CENTER
Request for Financial Assistance
In order to remove financial barriers for youth to participate in Lakeland Youth Center activities, limited funds are available to
offset program costs
All requests are reviewed on an individual basis
Parent / Guardian must complete this form entirely (partially completed forms will NOT be accepted)
One scholarship awarded per child per calendar year for sports programs
One scholarship awarded per child per school year for preschool
Copy of two different forms of income verification per household required. Please include additional
circumstances if they apply. Examples include: current pay check stub, last income tax return, child
support verification, W-2 from previous year, medical bills, unemployment, or verification from the
school of free/reduced lunch.
Scholarships awarded will be for half the cost of the original price.
FINANCIAL ASSISITANCE REQUEST FORMS MUST BE TURNED IN WITH REGISTRATION BY THE DUE DATE
1 hour of donated time helping out with a Lakeland Youth Center function will be required by the parent. A Lakeland Youth
Center representative will contact you to sign up for a specific event.
Program (Circle One):
Preschool
Spring Soccer
Fall Soccer
Flag Football
Basketball
Todd/Kinder Gym
Other___________
Child’s Name: _______________________________________________________________________________________________
Parent / Guardian Name: ___________________________________________ Phone: _____________________________________
Address, City, State, Zip: _______________________________________________________________________________________
Email Address: ______________________________________________________________________________________________
Estimated household income (annual) ___________________________________________________________________________
Household Number of Adults: __________________________ Household Number of Children: ____________________________
Comments: _________________________________________________________________________________________________
____________________________________________________________________________________________________________
LAKELAND YOUTH CENTER USE ONLY
APPROVED – Financial Assistance in the amount of $_________________
Applicant’s Current Balance: $ ____________________________
REJECTED – reason ________________________________________________________________________________________________________________
Authorized Signature ______________________________________________________________________
Date ________________________________________
Rev. 07/15
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