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2. Parent/Guardian Name:*
4. Address*
6. City*
7. State*
8. Zip Code*
10. Phone Number*
11. Email Address*
13. List dependent (17 and younger) that you are requesting assistance for. If applying for more than one dependent, please complete one form for each dependent or contact the office for a PDF application:
15. Child's Name:*
16. Birthdate:*
18. List each program number that you are requesting scholarship funding for:
20. Program #:
21. Program #:
22. Program #:
24. Program #:
25. Program #:
26. Program #:
28. Please indicate the method of qualification:*
    -- Select One --School Lunch ProgramDakota CountySocial Security
29. Upload documentation here or email to: recreation@lakevillemn.gov
31. I verify that the individuals listed above reside at the above address and are claimed by me as dependents for income tax purposes.
33. Type full name and date:*
Leave This Blank:


35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

37. Submit

* indicates a required field