Goodwill Scholarship Program Form 2015 Page 2
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2FEE ASSISTANCE APPLICATION
RECREATION & AQUATICS
Fiscal Year 2015-2016
City of Chandler Community & Neighborhood Services Department
Applicant Information:
Parent / Guardian / Applicant’s Full Name: _________________________
Address:
Zip Code:
Phone (primary):
Phone (secondary):
Email: ________________________________________________________________________________________
Place of Employment (if applicable):
Annual Income: $
Type of Income:
Spouse’s Full Name (if applicable): ______
Phone (primary):
Phone (secondary):
Place of Employment (if applicable):
Annual Income: $
Type of Income:
Number of family members in household: _____________
List all family members in household:
Family Member / Applicant Name
Relationship
Date of Birth
Age
Family Member / Applicant Name
Relationship
Date of Birth
Age
Family Member / Applicant Name
Relationship
Date of Birth
Age
Family Member / Applicant Name
Relationship
Date of Birth
Age
Family Member / Applicant Name
Relationship
Date of Birth
Age
Family Member / Applicant Name
Relationship
Date of Birth
Age
I certify that all information provided is true and correct and all names listed are family members residing in the household.
Applicant Signature: _______________________________________________
Date: ________________
Official Use Only
Scholarship Coordinator:
Division Manager:
q Approved
q Denied
Date Received:
Reason Denied (if applicable):
Completed application will be reviewed by a designated representative from the Community & Neighborhood Services Department.
Revised 3/2015
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