Today's Date

MM

DD

YYYY

I am applying for *

$25

$50

$100 (max amount per year)

Name *

First Name

Last Name

Phone

(###)

###

####

I understand that there are limited amounts of scholarship funds available to seniors who are truly in need. I understand that the funds awarded to me are not transferrable to another person. I understand that the funds awarded to me are not eligible to be used towards the lunch program. I understand that credits will not be awarded for missed classes or late cancellations (within 2 business days of scheduled activity or day trip). I understand that I must utilize the funds awarded to me prior to June 15, 2021. I understand that if I am applying for a new membership, I must also fill out a separate membership form. *

By checking this box, you have read and agree to the above statements

My Scholarship will pay for *

SASC Membership

Classes

Workshops (TED Talks, etc.)

Day Trips

My need for a scholarship or reduced payments is evident by: *

I receive CalFresh

I am on Section 8

I am on MediCal

I prefer not to answer but offer this explanation for consideration of my application below: