Senior Living Membership Scholarship Application

To help seniors pay for their membership at the Boardman Park and Recreation Center and promote healthy living.

*Scholarships available while funds last.*

Name Name * First Last
Phone Phone * - ### - ### ####
Email *
Address Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Household Assistance Received

(Check all that apply)
*

SNAP OR HEALTH PLAN SSA/SSI BENEFITS
GROSS YEARLY INCOME * $ Dollars . Cents
GROSS MONTHLY INCOME * $ Dollars . Cents
I certify that the above information is true and correct and that all household income is reported. I will notify Boardman Park & Recreation District of any changes. I am a resident of Boardman. I understand that providing false or incomplete information to the district will result in the immediate loss of financial assistant. *

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date Date * / MM / DD YYYY

Senior Living Membership Scholarship Application

Senior Living Membership Scholarship Application

Household Assistance Received