Park District of Oak Park

Please provide the following information Applicant/Parent/Guardian's Name Cell Phone Home Phone Address Oak Park, IL Zip Are you currently employed? Yes No E-Mail Number of persons in household: Children Adults Years/Months as an Oak Park resident: Years Months Do you: Own? Rent? Have you ever received a scholarship from the Park District of Oak Park? Yes No If you answered no, how did you hear about the scholarship? Online Brochure Word of Mouth School Other Current year's total projected household income from all sources (please circle range). less than $15,000 $25,000-$35,000 $15,000-$20,000 $35,000-$45,000 $20,000-$25,000 (If above $45,000 list amount) Type of proof provided: Are you a recipient of Public Aid, Unemployment or Aid to Dependent Children (ADC)? Yes No Are you currently receiving Energy Assistance Funds through Oak Park Township? Yes No Is your child (ren) in the free subsidized lunch program at school? Yes No Is your child (ren) in the reduced subsidized lunch program at school? Yes No Public Aid # (if applicable) Would you be interested in volunteering opportunities with the Park District of Oak Park? Yes No Race/Ethnicity (*Optional data will be used for Oak Park Township Statistics) American Indian or Alaska Native Black or African American Hispanic, Latino or Spanish Middle Eastern or North African Native Hawaiian or other Pacific Islander White Choose Not to Answer Other (please specify) Please make sure all paperwork is completely filled out and submitted so the process is not delayed. If you have questions, please contact Customer Service with the Park District of Oak Park at 708.725.2000. 3 Scholarship Program 2022 January 2022-December 2022 Funded by the Park District of Oak Park & Oak Park Township Please provide the following information regarding all family members who will be using the scholarship Name (Last, First) Date of Birth Grade Gender (M/F) Your relationship to name listed Check if request is for Childcare (Camps/Preschool)

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