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_ <br />_ _ _ <br />� EN HILLS <br />Arden Hills Parks and Recreation <br />FEE ASSISTANCE APPLICATION <br />Eligibility Requirements: <br />1. The participant must be a resident of Arden Hills. <br />2. The family must be eligible for the free or reduced lunch program at school or receive public <br />assistance. <br />3. The family must provide documentation (school district letter, WIC card, or other form) that they <br />are on the free or reduced lunch program for the current year or other public assistance program. <br />Fee Assistance Program: <br />1. Each individual in a qualifying family may receive full assistance up to $40, depending on funding <br />availability. <br />2. The program limits assistance to one class per quarter per individual. <br />3. Participants will be responsible for paying any additional fees for materials, rentals, etc. <br />4. The following programs are exempt (but not limited to): Summer sports camps, specialty drama <br />and science camps, and field trips. <br />5. All information submitted for the purposes of eligibility determination into the Fee Assistance <br />Program is considered confidential and is not shared with the staff working in the programs. <br />Parent's Name: Phone: <br />Address: City: Zip: <br />School Attending: <br />Is the family on free or reduced lunch program or public assistance? <br />Child's Name Grade Activity Title Activity # Fee <br />Y N <br />Fee w/assistance <br />TOTAL DUE: <br />SIGNATURE <br />I certify that all of the above information is true and correct. I understand that school officials may verify the information on this <br />application. <br />[Signature of Parent or Guardian] [Date] <br />