City of Mill Creek

The scholarship program provides support to Mill Creek residents that are eligible applicants for participation in Mill Creek Recreation programs. Scholarships are available to pay up to 50 percent of program/class fees (not to exceed $50). Applicants are required to pay the difference between the program fee and the scholarship fee at the time of registration. After the form is submitted, staff will contact the adult household member regarding scholarship status. Each family member is eligible for one scholarship per quarter.

Parent/Guardian First Name:*

Parent/Guardian Last Name:

Address:*

City:*

Zip:*

Primary Phone #:*

Alternate Phone #:

Email:*

Child's First Name:*

Child's Last Name:*

Birthday:*

Grade:

School

2nd Child's First Name

2nd Child's Last Name

2nd Child's Birthday

2nd Child's Grade

2nd Child's School

Does your child(ren) receive free or reduced lunch at school?

yes

no

Does your child(ren) receive basic food, TANF (Temporary Assistance for Needy Families) or FDPIR (Food Distribution Program on Indian Reservations)?

Yes

No

Alternate Forms of Income:

Please list the names of additional adults in your household

Please list the names of additional children in your household (do not include the name of the child listed above)

Please list each household member's income (their monthly earnings from work before deductions)

Please list each household member's monthly child support, alimony or welfare

List the activity that your child wishes to enroll in.*

What is this activity's course number?

What is the fee of this activity?

2nd Child: List the activity that your child wishes to enroll in.

2nd Child: What is this activity's course number?

2nd Child: What is the fee of this activity?

What is your child's shirt size?

--Select One--Youth SmallYouth MediumYouth LargeYouth X-LargeAdult SmallAdult MediumAdult LargeAdult X-Large

What is your child's grade?

--Select One--Kindergarten1st Boys1st Girls2nd Boys2nd Girls3rd Boys3rd Girls4th Boys4th Girls5th Boys5th Girls6th Boys6th Girls7th Boys7th Girls8th Boys8th Girls

What school does your child attend?

2nd Child: What is your child's shirt size?

--Select One--Youth SmallYouth MediumYouth LargeYouth X-LargeAdult SmallAdult MediumAdult LargeAdult X-Large

2nd Child: What is your child's grade?

--Select One--Kindergarten1st Boys1st Girls2nd Boys2nd Girls3rd Boys3rd Girls4th Boys4th Girls5th Boys5th Girls6th Boys6th Girls7th Boys7th Girls8th Boys8th Girls

2nd Child: What school does your child attend?

With my signature above and as a condition of the City, Myself or my child(ren) will assume all risks and hazards incidental to participating in City of Mill Creek Parks and Recreation activities, and do hereby waive, release, absolve, indemnify, and agree to hold harmless the City of Mill Creek, and its employees, supervisors, participants, and instructors, for any claim arising out of any injury, damage, or personal loss incurred to myself or my child(ren) in connection with the activities sponsored or co-sponsored by Mill Creek Parks & Recreation. I, the undersigned, am fully aware of the potential dangers and risk inherent in these activities, including physical injury, death, or other consequences that may arise or result directly or indirectly from participation in these activities. By participating in Mill Creek Parks and Recreation activities, I agree that any images of myself or my child(ren) may be used by the City of Mill Creek and may be included in promotional materials, newspaper articles, and/or newsletters relating to Mill Creek Parks and Recreation activities.*

Type in your first and last name for the above waiver*

Receive email copy

Email address

This field is not part of the form submission.

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