FYHA News > Forms & Policies

FYHA Scholarship Request Form

P.O. Box 2903, Flagstaff, Arizona 86003

Participant Name: _______________________________________________

Age: _____Gender: _____ Birth Date: ______________________

Parent/Guardian: ______________________________________

Contact Number: ______________ Email: ___________________________

Address:_________________________________________________________ ________________________________________________________________

            Street                                       City                              State                Zip

 

School Child Attends:_______________________________ Grade:__________

 

Annual Income: _____________Number of family members in household:_____

 

Does your child qualify for free or reduced school lunch?                       YES     NO

Has your family experienced a sudden financial hardship?                      YES     NO

 

If yes to sudden financial hardship, please briefly explain: ______________________________________________________________________

______________________________________________________________________

 

What program is your child registering to participate in?                         

(Please circle one that applies)

House Programs	Travel Programs
Mini Mite (4-8yr) (Learn to Skate)	Mite (5-8yr)
Mite (5-8yr)	Squirt (9-10yr)
Squirt Peewee Bantam (9-14yr)	Peewee (11yr-12yr)
	Bantam (13yr-14yr)

 

What amount of Scholarship are you requesting?  Please check which one applies: 10%____   25%-_____   50%_____   Full ______  Other _____

 

Are you requesting scholarship money for rental equipment too? YES     NO

Has your child ever received a scholarship from FYHA?              YES     NO

 

Are you willing to volunteer with FYHA to help defray costs?       YES     NO

If yes, please list which volunteer job(s) you have signed up for 09/10 ____________________. (sign up before turning this form in, you can get our volunteer list by visiting www.fyha.org and click on �Volunteer List� and then sign up for the one(s) that apply).

 

FYHA Scholarships are granted according to:

�         Availability of funds

�         Financial need of applicant

�         Participant commitment to practices and games

�         Volunteer commitment

 

I hereby certify that all of the information on this from is true and correct.  I understand that the Flagstaff Youth Hockey Association may verify this information.  Deliberate misrepresentation may be subject to termination of further financial assistance.

 

Authorized Signature: __________________________ Date:_______________

Printed Name: _________________________________________________________