Eugene, OR Website

Safety Town Scholarship Application 2020

Steps

1. Funding for Safety Town 2020 This section is complete This section is incomplete
2. List each child applying for a scholarship This section is complete This section is incomplete
3. Signature This section is complete This section is incomplete

Funding for Safety Town 2020

Application Guidelines
Eligibility: You must be a City of Eugene resident residing in the incorporated area of Eugene and your income must be within program eligibility guidelines.<br><br>Application approval does not guarantee reservation of funds or registration in camp: Scholarships are limited and awarded on a first-come, first-served basis for all eligible participants. You will be notified if approved and funding will be disbursed accordingly. </br>
Eligibility: You must be a City of Eugene resident residing in the incorporated area of Eugene and your income must be within program eligibility guidelines.

Application approval does not guarantee reservation of funds or registration in camp: Scholarships are limited and awarded on a first-come, first-served basis for all eligible participants. You will be notified if approved and funding will be disbursed accordingly.
Scholarship Award:
If you are eligible for a Safety Town scholarship, you will receive a $30 discount from the $60 camp fee. ($30 remaining fee)
Main Contact Information
To be completed by adult applicant or parent/guardian if applicant is under 18 years of age.
Main Contact First Name*
Main Contact Last Name*
Birth date*
Homeless?*
1. Yes
1. No
What is the best way to contact you?
Street Address*
City*
Zip Code*
Mailing Address
(if different from street address)
City
Zip Code
Phone #
Email
TOTAL household average MONTHLY gross income (before taxes):*
Include child support, alimony, unemployment, self-employment, social security, pensions and veteran's payments, regular contributions from persons not living in the household, and any household income from all household members.
# of people in household supported by this income*
Check any public assistance program from which you currently receive benefits:
1. Oregon Health Plan
2. Social Security Benefits
3. Unemployment
4. Food Stamps (SNAP)
5. Other
If other, please explain:
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List each child applying for a scholarship

Child #1
First Name*
Last Name*
Gender*
Birth date*
Child #2
First Name
Last Name
Gender
Birth date
Child #3
First Name
Last Name
Gender
Birth date
Child #4
First Name
Last Name
Gender
Birth date
Is there anything else you would like us to consider when reviewing your application?
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Signature

Signature statement
I hereby certify that all of the above information is true and correct and that all income is reported. I understand that deliberate misrepresentation may result in denial of eligibility for a Safety Town Scholarship. Proof of income may be required upon request.
Signature of Applicant (or parent/guardian)*
Status
Notified
Date notified/Initials
Notes

Leave This Blank:

1. Receive an email copy of this form.
Email address

This field is not part of the form submission.
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Safety Town Scholarship Application 2020

Steps

Funding for Safety Town 2020

List each child applying for a scholarship

Signature

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