Application for Program Scholarship

All information is for Parks & Recreation use only.

Village of Archbold Department of Parks & Recreation
300 N. Defiance Street
Archbold, OH 43502

* required field

Child's Name*

Child's Date of Birth*

Gender*

School*

Grade**

Parent's/Guardian's Name**

Street Address*

City*

Zip*

Phone*

Alternate Phone

Email Address

Program Name*

Program Season*

Do you particpate in the school's free and reduced program?

Free Lunch ParticipantReduced Lunch Participant

I authorize the Archbold Area School District to release information regarding free/reduced lunch program participation to the Village of Archbold Department of Parks & Recreation. (Must be selected if choosing either of the lunch programs above.)

Please make applicable selections

I understand that if I qualify for the Free Lunch program that I will be required to pay for 25% of the registration fee.

I understand that if I qualify for the Reduced Lunch program that I will be required to pay for 50% of the registration fee.

I understand that my child will be eligible for two scholarships per year and that I am responsible for the registration fees for all subsequent programs this calendar year.

I understand that program scholarships are distributed on a first come first serve basis and that I am not guaranteed a scholarship for any program.

Please give a brief explanation of why you would like your child to receive a scholarship*

* I certify that the above information is true and complete to the best of my knowledge. I understand that scholarship assistance is based on need and financial need does not automatically guarantee selection.