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First Name _______________________________________________ Last Name ___________________________________________________ <br />Address ________________________________________ City ____________________________State ________ Zip Code ____________ <br />Cell Phone _____________________________ Email __________________________________________________________________________ <br />Scholarship Program <br />Application Form <br />Questions <br />If you have any questions please list in this box. <br /> <br /> <br />Scholarships Available <br />Please circle the scholarship you are applying for <br />• 50% off Program Registration <br />• 25% off Membership Fees <br /> <br />City of Lino Lakes residents and the surrounding community who are unable to pay the full fees for The Rookery Activity Cente r <br />membership or programs may apply to receive a scholarship for reduced rates. Individuals requesting assistance will be re- <br />quired to show proof to meet the eligibility guidelines and will be asked to pay a portion of the fees. Funds are available o n a first <br />-come, first-serve basis. Individual may apply for a scholarship once per year for membership funds and once per 6 months for <br />program funds. <br />Eligibility Requirements - If you currently participate in any of the following programs, you are eligible to apply for <br />a scholarship. Please provide documentation of participation in the program . <br />• Supplemental Nutrition Assistant Program (SNAP) form <br />• Nutrition Services - reduced lunch form from School District <br />• Anoka County General Assistance <br />• Minnesota Supplemental Aid <br />For Office Use Only: <br />Scholarship Application Received - Date________________ ❑ <br />Received Eligibility Yes ❑ No ❑ <br />Scholarship Awarded: Type: __________________________________________________ <br />Amount # _________________________ Authorized by ________________________________________________________Date _____________________ <br /> (Rookery Activity Center Staff)