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? How did you hear about the Childcare Discount Membership? (please circle) Online Brochure Word of Mouth School Other Current year's total combined household adjusted gross income (please circle) less than $39,000 $39,001-$65,000 $65,001-$100,000 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 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) 2 Childcare Discount Membership (CDM) Program 2022 January 2022-December 2022 Funded by the Park District of Oak Park & Oak Park Township I ____________________________ hereby certify that all information on the application is true and accurate. Scholarships are legally recoverable if paid and awarded based on false information supplied by the applicant. The submission of false information will nullify any request for waiver of program fees. ___________________________________________ _______ / _______ / 20___ Signature of Applicant's Parent/Legal Guardian Date

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