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2. Recreation youth scholarships are available to Campbell residents ages 0-17 or students currently enrolled at Rosemary Elementary School. You must complete the online form below and upload required documents before your application can be processed.
4. Parent/Guardian Contact Information
6. First Name*
7. Last Name*
9. Address1*
11. Address2
13. City*
14. State*
15. Zip*
17. Home Phone Number*
18. Email Address*
20. Employer*
21. Work Phone Number
22. Marital Status*
    -- Select One --SingleMarriedDivorced Widowed
24. Spouse’s Name*
25. Spouse’s Employer*
26. Spouse’s Work Phone
28. Number of Adults in Home*
    -- Select One --12345 or more
29. Number of Children in Home*
    -- Select One --12345 or more
30. Number of Children Requesting Aid*
    -- Select One --1234
32. Child First Name*
33. Child Last Name*
35. Relation*
36. Birthdate*
    Birthdate
37. Child currently enrolled at Rosemary Elementary for 2021-2022 school year?*
    -- Select One --YesNo
39. Grade*
    -- Select One --TKK12345

    2021-2022 School Year

40. School*

    Currently enrolled for 2021-2022 school year.

42. Child 2 First Name*
43. Child 2 Last Name*
45. Relation*
46. Birthdate*
    Birthdate
47. Currently Enrolled at Rosemary Elementary for 2021-2022 School Year*
    -- Select One --YesNo
49. Current Grade*
    -- Select One --TKK12345

    2021-2022 School Year

50. School*

    Currently enrolled for 2021-2022 school year.

52. Child 3 First Name*
53. Child 3 Last Name*
55. Relation*
56. Birthdate*
    Birthdate
57. Currently Enrolled at Rosemary Elementary for 2021-2022 School Year*
    -- Select One --YesNo
59. Current Grade*
    -- Select One --TKK12345

    2021-2022 School Year

60. School*

    Currently enrolled for 2021-2022 school year.

62. Child 4 First Name*
63. Child 4 Last Name*
65. Relation*
66. Birthdate*
    Birthdate
67. Currently Enrolled at Rosemary Elementary for 2021-2022 School Year*
    -- Select One --YesNo
69. Grade*
    -- Select One --TKK12345

    2021-2022 School Year

70. School*

    Currently enrolled for 2021-2022 school year.

72. Please list your reason for assistance. Explain any special circumstances you may wish us to consider:
74. Have you received financial assistance from the City of Campbell Recreation Department before?*
    -- Select One --YesNo
76. What year(s) did you receive assistance?*
77. What program(s) did your child attend?*
79. I certify that the above information is true and correct and I understand that the information provided here will be relied upon for purpose of determining our eligibility to receive financial assistance from the City of Campbell Recreation & Community Services Department and tha t any misstatement, fraudulently or negligently made in this or in any other statement by me may result in the denial of my eligibility to receive financial assistance. I authorize the City of Campbell to verify the above information. I agree to provide additional documentation to verify my need if requested.
81. Signature*
82. Date*
    Date
84. Information

    1. I would like the City to keep this information private to the extent permitted by law. Please notify me before releasing this information to anyone outside of the City.
88. File Upload

    ***Proof of Campbell Residency and Proof of Income is required for your application to be processed.

90. Proof of Campbell Residency

    Provide one of the following for residency verification: 1. Copy of Driver’s License or State Identification. 2. Last three months of utility bills

92. Proof of Income
    Provide one of the following: 1. Proof from the school district that your child is eligible for free or reduced price meals. 2. Proof that your family is receiving Food Stamps, CalWORKS assistance (California Work Opportunity & Responsibility to Kids), TANF (Temporary Aide to needy families), or Kin-GAP (Kinship Guardian Assistance Payments). 3. If you do not have either of the above, a copy of your last Federal Income Tax Return (form 1040/1040EZ/1040NR) showing that you fall under the income eligibility Guidelines. Your household size must equal the number claimed on your income tax form.
94. ***Proof of Rosemary Elementary School Enrollment

    ***Required for Rosemary Elementary students ONLY. Provide all of the following: 1. Letter of 2021-2022 enrollment from the school. 2. School district free or reduced lunch award letter.

Leave This Blank:


96. 1. Receive an email copy of this form.
97. Email address

    This field is not part of the form submission.

98. Submit Submit and Print

* indicates a required field