LEEWARD AYSO 269 SCHOLARSHIP APPLICATION FORM PLAYER

LEEWARD AYSO 269 SCHOLARSHIP APPLICATION FORM

PLAYER INFORMATION Gender:  Male  Female Birthdate: Age:

Player’s Name: Address: PARENT/GUARDIAN INFORMATION Name: Address:

Work Phone: Home Phone: Cell Phone:

Email: Child Lives with:  Father  Mother  Both Parents  Other List names of other adults living in the household:

FINANCIAL BACKGROUND Is your child receiving/eligible for school lunches/meals?

 Yes  No

Annual Family Gross Income: $ Number of people living in the household: How much of the registration fee can you pay? $

Children

Adult(s)

(Minimum amount is $30.00)

ADDITIONAL INFORMATION Please provide us some information about your financial or other situation that will assist us in our decision:

Have you received a Playership Grant from AYSO in the past?  Yes

 No

I have answered the above questions to the best of my ability. I have been honest about the family’s situation. Parent/Guardian Signature: This section to be completed by the Region:  Approved Reviewed by: Registrar Treasurer Regional Commissioner

Date:  Not Approved Date: Date: Date: