Get Rec Pac

REC-PAC PARTIAL SCHOLARSHIP APPLICATION Please complete a separate form for each eligible child A limited number of partial scholarships are available for Rec-PAC. Scholarship requests must be attached with a completed Rec-PAC registration form due by June 14th Member Number See Parktakes Magazine Mailing Label School Attending Now Child s Name /Age Birthdate // Last Grade In Fall First Parent/guardian Name / print clearly Daytime Phone Number Home Phone Other Phone Number Family address Street City Zip To Qualify Who is Eligible Fairfax County residents who receive public assistance are eligible for a partial scholarship. To receive a partial scholarship you must provide proof of eligibility with ONE of the following 1. All but 12 per week will be covered through the scholarship program* Parents must pay a 12 co-pay per week per child. See below for eligibility requirements. Partial Scholarships do not qualify for the 8 early registration discount and there are no refunds for scholarships. Signature from School Administrator Parent Liaison or County Social Worker 2. Proof of Eligibility Letter Attach a copy of the letter from the agency that is providing assistance My child is currently enrolled in the following public assistance program s Please check all that apply Free or Reduced School Lunches TANF Aid to Dependent Children Foster Care Food Stamps Other Reason describe Name of staff person to verify eligibility Print name Signature Date Position Phone School and Weeks requested Rec-PAC Location See Rec-PAC brochure for a listing of school locations Please check all weeks that apply Week 1 July 1-July 3 3 days TOTAL of Weeks x 12 per week Amount Due Check Enclosed or Money Order Enclosed Week 4 July 22-July 26 Credit Card /// Exp* Date/ Week 5 July 29-August 2 Credit Card Signature Week 6 Aug 5-Aug 8 4 days Please Forward To Rec-PAC Fairfax Co. Park Authority 12055 Gov t Center Pkwy Suite 425 Fairfax VA 22035 Completed forms with signatures will be accepted* Plan to attend the weeks selected above unless notified otherwise. CONSENT FORM I give my permission for the Fairfax County Public Schools or Department of Family Services to release information verifying my eligibility and permission for Fairfax County Government to determine my eligibility. All but 12 per week will be covered through the scholarship program* Parents must pay a 12 co-pay per week per child. See below for eligibility requirements. Partial Scholarships do not qualify for the 8 early registration discount and there are no refunds for scholarships. Signature from School Administrator Parent Liaison or County Social Worker 2. Proof of Eligibility Letter Attach a copy of the letter from the agency that is providing assistance My child is currently enrolled in the following public assistance program s Please check all that apply Free or Reduced School Lunches TANF Aid to Dependent Children Foster Care Food Stamps Other Reason describe Name of staff person to verify eligibility Print name Signature Date Position Phone School and Weeks requested Rec-PAC Location See Rec-PAC brochure for a listing of school locations Please check all weeks that apply Week 1 July 1-July 3 3 days TOTAL of Weeks x 12 per week Amount Due Check Enclosed or Money Order Enclosed Week 4 July 22-July 26 Credit Card /// Exp* Date/ Week 5 July 29-August 2 Credit Card Signature Week 6 Aug 5-Aug 8 4 days Please Forward To Rec-PAC Fairfax Co. Park Authority 12055 Gov t Center Pkwy Suite 425 Fairfax VA 22035 Completed forms with signatures will be accepted* Plan to attend the weeks selected above unless notified otherwise.