[San Francisco Recreation and Parks] Scholarship Request Form

Online Scholarship Request Form

San Francisco Recreation and Parks
Overview
Do you have SF Recreation and Park Family Account?*
Register here at: sfrecpark.org/register to set up your account and then return to this form. Be sure to add all family members to your account for them to be included in the scholarship program.
Contact & Household Information
1. Head of Household Name*
Please enter Full Name
Head of Household Birthdate*

MonthDayYear
Head of Household Gender*
Head of Household Race/Ethnicity*
2. Email address*
example@domain.com
3. Street Address*
e.g.. 501 Stanyan St
City*
e.g. San Francisco
State*
e.g. California -CA
Zip Code*
e.g. 94117

Family Member(s) Information
Family Member #1 Name
Please enter Full Name
Family Member #1 Birthdate

MonthDayYear
Family Member #1 Gender
Family Member #1 Race/Ethnicity
Family Member #2 Name
Please enter Full Name
Family Member #2 Birthdate

MonthDayYear
Family Member #2 Gender
Family Member #2 Race/Ethnicity

Family Member #3 Name
Please enter Full Name
Family Member #3 Birthdate

MonthDayYear
Family Member #3 Gender
Family Member #3 Race/Ethnicity
Family Member #4 Name
Please enter Full Name
Family Member #4 Birthdate

MonthDayYear
Family Member #4 Gender
Family Member #4 Race/Ethnicity

Total Household Income*
Total family members living in household*
Do you live in Public Housing?*
Are you unhoused?*
Are any children in your household Foster children?*
Name(s) of Foster children*
5. Are you currently enrolled in any government subsidies (Medi-Cal, Cal Works, Cal Fresh)? *
Eligibility Verification

To apply, you will either need to allow us access to the San Francisco Human Services Agency (HSA) Income Verification Database and provide the last 4 digits of your social security number OR you will need to upload supporting documents. Please note that the Income Verification Database has data for individuals on Medi-Cal, CalFresh, CalWORKs, or CAAP (approximately 1 in 4 San Franciscans). If you are not participating in any of these programs, please select option 2 and upload verification documents.
Please check all subsidies you receive*

Medi-CalCalFreshCalWORKs

To apply, you will either need to allow us access to the San Francisco Human Services Agency (HSA) Income Verification Database and provide the last 4 digits of your social security number OR you will need to upload supporting documents. Please note that the Income Verification Database has data for individuals on Medi-Cal, CalFresh, CalWORKs, or CAAP (approximately 1 in 4 San Franciscans). If you are not participating in any of these programs, please select option 2 and upload verification documents.
Eligibility Verification Option 1: I give permission to the San Francisco Human Services Agency (SFHSA) to share limited income information with the San Francisco Recreation and Parks Department (SFRPD) to help determine whether I may qualify for scholarships. My information shall be shared only as needed for those purposes. I understand that this database can only show my name, my address, and whether my household income falls within certain percentages of federal poverty guidelines based on information I have previously provided to HSA. This release of information expires one year from the date I sign below, unless I cancel it in writing before then.
Last Four Digits of Social Security Number*
Full Name*
Email*
example@example.com
Sign Here*

If NO,

Eligibility Verification Option 2: To qualify, you must upload income eligibility and verification documentation.

Applicant’s household must have an income equal to or less than 250% of the current federal poverty level, as determined by the U.S. Department of Health and Human Services’ Federal Poverty Guidelines 2023.

Upload Documentation required
- 50% Scholarship Level: Requires prior year income tax return OR Current SSI (Supplemental Security Income) statement
- 100% Scholarship Level: Requires 2 of the following public assistance program verifications
  MediCal— provide current Notice of Action letter
CalWORKS— provide current Notice of Action letter

Food Stamp— provide current Notice of Action letter

Public Housing Authority— provide rent receipt

Foster Care— provide court order letter
Upload Verification Document 1 *

Cancelof
Upload Verification Document 2

Cancelof
Upload Verification Document 3

Cancelof

Scholarship Agreement and Liability Waiver
Scholarship Agreement

1. I understand that for scholarship recipients to retain or to qualify for future financial assistance, reasonable attendance for each program (75%) is required. I will not register for summer day camp programs during any portion of personal vacation/trips.
2. I agree to contact the program instructor prior to the start of the class if the participant needs to miss a class due to illness or other reason. If the participant needs to miss more than one class due to illness or other emergency, I agree to email RecScholarships@sfgov.org or call 628-652-2900.
3. If I need to withdraw from a class, I agree to the minimum $15 withdrawal fee (maximum of 20% of the class fee if l am receiving a 50% scholarship), payable at the time of the withdrawal.
4. I understand that excessive withdrawals or late withdrawals (less than 1 week before the class starts) will result in cancellation of my household scholarship.
San Francisco Recreation and Park Department Program Participation Liability Waiver

I recognize that risk of injury or potential health risk may be involved in participation in the programs offered by the City of San Francisco Recreation & Park Department. I hereby willingly assume such risk of injury or health risk for myself or for the persons for whom I am lawfully responsible and assume full responsibility before, during and after my/their participation in the programs/activity offered by the City of San Francisco Recreation & Park Department.

In consideration of the acceptance of my application and the permission to participate in programs offered by the City of San Francisco Recreation & Park Department, I, for myself, my heirs, executors, administrators, successors and assigns hereby release, waive, and forever discharge the City of San Francisco, all other organizations, associations and companies associated with any of the programs offered by the City of San Francisco, and their respective agents, employees, officials, servants, contractors, representatives, elected and appointed officials, successors and assigns of and from all claims, demands, damages costs and actions whatsoever and however caused, arising or to arise by reason of my participation in the programs or activities or any of its associated activities.
Full Name*
Should be Empty:

Online Scholarship Request Form

Overview

Contact & Household Information

Family Member(s) Information

Eligibility Verification

Scholarship Agreement and Liability Waiver