Fort Collins
 Loveland
484-5198
663-5450
2013 Summer Morning Drop-Off Scholarship Application
Please complete this application if you need scholarship assistance for your child/children to
attend Early Mornings at the Fort Collins or Loveland Club.
The Summer Early Morning Drop-Off is offered, Monday – Friday, 7:30-11:00 a.m.
The regular fee is $10/day for one child or a family rate of $15/day.
In order to be eligible:
1. Parents/Guardians must be working, seeking employment or in school during Drop-Off time
2. Families must fall within the following income guidelines:
Household Size
2
3
4
5
6
7
8
Annual Income
$0 - $30,700
$30,701 - $34,550
$34,551 - $38,350
$38,351 - $41,450
$41,451 - $44,500
$44,501 - $47,600
$47,601 - $50,650
What are you able to pay? (circle one)
$0/day
Weekly Income
$0 - $519
$510 - $652
$653 - $785
$786 - $918
$919 - $1,051
$1,052 - $1,184
$1,185 - $1,317
$1/day
$3/day
$5/day
Parent/Guardian Full Name ________________________________________________________
1st Member Full Name________________________________________ Member No.____________
2nd Member Full Name________________________________________ Member No.____________
3rd Member Full Name________________________________________ Member No.____________
4th Member Full Name________________________________________ Member No.____________
HOUSEHOLD INFORMATION
Number of Children ______ Number of Adults ______
CHECK ALL THAT APPLY:
□ Single Parent
□ Foster Family □ Unemployed □ Disabled □ Attending School □ Homeless/Shelter
Please explain your need for a scholarship: (continue on back if needed)
______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Parent/ Guardian Signature________________________________________ Date_____________________
Morning Drop-Off Time__________ Days of Week Needed (circle) M
T
W
Th
F
Office Use Only
Approved for scholarship by Unit Director _____________________Executive Director __________________