Park District of Oak Park

Please provide the following information Are you applying for the Scholarship, CDM, or both? Scholarship CDM Both Applicant/Parent/Guardian's Name: Address: Email: Phone #: Are you currently employed? Yes No Number of persons in household: Children Adults Years/Months as an Oak Park resident: Years Months Do you own or rent? 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 Program Guide Word of Mouth School Other Current year's total projected household income from all sources (please check range) less than $15,000 $15,000-$20,000 $20,000-$25,000 $25,000-$35,000 $35,000-$45,000 (If above $45,000 list amount) Type of proof provided: Are you a recipient of Public Aid, Unemployment or Aid of Dependent Children (ADC)? Yes No Is your child(ren)/dependent in the free or reduce subsidized lunch program at school? Yes No If checked yes, do you give PDOP permission to confirm this with the school? Yes No Note: If you do not give permission, please provide proof or residency, dependency, and income documents. Please provide Public Aid # (if applicable) Race/Ethnicity (*Optional data will be used for Oak Park Township Statistics) American Indian or Alaska Native Black or African American Prefer Not to Answer Middle Eastern or North African Hispanic, Latino or Spanish Other White/Caucasian Native Hawaiian or Other Pacific Islander Please provide the following information regarding all family members who will be using the scholarship Name (Last, First) Date of Birth MM/DD/YY Grade Your Relationship to name listed Check if applying your dependent for the (CDM) Financial Assistance Program 2023 January 2023-December 2023 APPLICATION FORM *PLEASE COMPLETE BOTH SIDES OF THIS APPLICATION

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