Today's Date *

Scholarship Form updated 4.11.23

MM

DD

YYYY

Name *

First Name

Last Name

Address *

Address 1 = Physical / Address 2 = Mailing

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Are you a current member of the Senior Center? *

If you are first time member, please also fill out a membership form.

YES

NO

Please read and check the box next to each line *

By checking each box, you agree and understand the scholarship process

I understand that there are limited amounts of scholarship funds available to seniors who are truly in need

I understand that the scholarship awarded to me is not transferable to another person.

I understand that scholarship credits will not be awarded for missed classes or cancellations.

I understand that if I am applying for a scholarship this year, I must also apply for every year after – It does not automatically renew

My need for a scholarship or reduced payments is evident by: *

I receive CalFresh

I receive Section 8

I receive MediCal

I prefer not to answer but offer this explanation for consideration of my application below: