Form Center

2. Sponsored by Color Country Pediatrics
   For youth ages 5-15 living within Iron County

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   The Youth Sport Scholarship fund is designed to provide supplemental financial assistance (up to 80% of registration fees) to youth who may not otherwise be able to participate in youth activities offered by Cedar City Leisure Services.

   Limited funds are set aside each year to help youth participate in instructional and organized programs/activities/classes held by Cedar City Leisure Services. Applicants will be limited to one sport scholarship per quarter.

   Financial eligibility for the scholarship fund will be verified by presentation of WIC and/or Medicaid benefits.

   This application does not register the participant for the program/activity/class. Any late fees incurred are the responsibility of the parent/guardian, and will not be paid for by this program.

   Information and Application Cedar City Leisure Services Youth Scholarship Fund, sponsored by Color Country Pediatrics, For youth ages 5-15 living within Iron County

   Cedar City Leisure Services 2090 W. Royal Hunte Dr. 435-865-9223 www.cedarcity.org

   Eligible programs/activities/classes include but not limited to:

   • Youth T-ball and Machine Pitch

   • Youth Basketball

   • Youth Flag Football

   • Youth Volleyball

   • Girl’s Hula

   • Swimming Lessons

   Scholarship funds are not eligible for:

   • Admission to Aquatic Center

   • Contracted programs

   • Association fees

   • Equipment and uniform fees

   * Applications need to be submitted 7 days prior to registration deadline.

   * No refunds of any kind will be granted if participant is registered at full price prior to scholarship approval.

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   Name of Child/Children applying for:

4. Number of Children*
   -- Select One --123456
6. Child 1
7. Date of Birth
   Date of Birth
8. Sport Program Applying for
   -- Select One --Youth T-Ball & Machine PitchYouth BasketballYouth Flag FootballYouth Volleyball
10. Child 2
11. Date of Birth
    Date of Birth
12. Sport Program Applying for
    -- Select One --Youth T-Ball & Machine PitchYouth BasketballYouth Flag FootballYouth Volleyball
14. Child 3
15. Date of Birth
    Date of Birth
16. Sport Program Applying for
    -- Select One --Youth T-Ball & Machine PitchYouth BasketballYouth Flag FootballYouth Volleyball
18. Child 4
19. Date of Birth
    Date of Birth
20. Sport Program Applying for
    -- Select One --Youth T-Ball & Machine PitchYouth BasketballYouth Flag FootballYouth Volleyball
22. Child 5
23. Date of Birth
    Date of Birth
24. Sport Program Applying for
    -- Select One --Youth T-Ball & Machine PitchYouth BasketballYouth Flag FootballYouth Volleyball
26. Child 6
27. Date of Birth
    Date of Birth
28. Sport Program Applying for
    -- Select One --Youth T-Ball & Machine PitchYouth BasketballYouth Flag FootballYouth Volleyball

30. ---

    Parent/Guardian Information

32. Parent/Guardian Name*
34. Address1*
36. City*
37. State*
38. Zip*
40. Main Phone Number*
41. Alternate Phone Number
42. Email*
44. Agreement *

    1. By clicking submit, I certify that all the information provided is correct and if, during the term of the scholarship, the information changes I will notify Cedar City Leisure Services
46. I understand*

    1. I understand that to qualify, I must provide verification that my child/children are eligible.
    2. I understand that Applications are subject to approval. The approval process can take up to 7 days. Applications need to be submitted 7 days prior to registration deadline.
    3. I understand that no refunds of any kind will be granted if participant is registered at full price prior to scholarship approval.
48. WIC and/or Medicaid Program Verification Upload*

    Click "BROWSE" to upload the letter from the folder you saved it too.

50. All information provided will be used only to determine eligibility for scholarships.

Leave This Blank:


52. 1. Receive an email copy of this form.
53. Email address

    This field is not part of the form submission.

54. Submit

* indicates a required field