PUBLIC HEALTH and SOCIAL SERVICES

David Bayne - Director

Dr. Dimyana Abdelmalek - Health Officer

COUNTY COMMISSIONERS

Carolina Mejia - District One
Gary Edwards - District Two
Tye Menser - District Three

Wayne Fournier - District Four

Emily Clouse - District Five

Specialized Recreation Scholarship Application

Complete Annual Participant Forms before completing the scholarship form. Do not register for activity until you receive confirmation of the scholarship award.
Scholarships are limited to a maximum of $60 each quarter. You must apply each quarter.
Scholarships can be used on any program(s). Any remaining funds do not carry over to the next quarter.
You must pay the balance of fees for your program(s) when you receive your invoice.
Our standard cancellation policy applies: You must notify our office 3 working days before the activity begins if you will not be attending.
Scholarship fees cannot be transferred to other programs or participants.
IMPORTANT: If you received a scholarship and you do not attend registered activity, you will be responsible for full payment of the program fees.
Call 867-2679 if you have questions.
Scholarships are subject to the availability of funds.

Participant Name: *

Phone Number *

E-mail Address *

Activity 1 - I would like to use $60 scholarship funds for (activity name, date, and cost):

Activity: *

List all scheduled dates of activity that you are requesting: *

Cost of activity: *

If you would like to use scholarship funds for more than one activity, include additional events below: Activity 2

Activity (2):

Date(s) of activity:

Cost of activity:

Activity (3):

Date(s) of activity:

Cost of activity:

Add additional activity information here, if needed:

Thank you to the PARC Foundation for donating Recreation Scholarship funds!

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412 Lilly Rd. N.E., Olympia, Washington 98506-5132

(360) 867-2679 FAX (833) 499-1806 TDD (360) 867-2603 TDD (800) 658-6384

www.thurstoncountywa.gov/phss