2. Please note:

   Program fee assistance is available to those demonstrating financial need. Because of limited scholarship funding, only Roseville residents are eligible to apply for fee assistance.

   Qualified applicants are eligible for assistance of up to 80% of the program fees (maximum, $150 per participant annually). Information provided will be treated confidentially and will be used only for eligibility determinations.

4. Complete the form and submit, including uploaded copies of the participant's registration form and proof of Roseville residency.

   Your application form submission will be acknowledged within a week of receipt. We recommend you print out your submission for your records.

6. Participant's name*
7. Date of birth*
   Date of birth
9. Address*
11. City*
12. State*
13. ZIP*
15. Phone*
16. Email
18. Parent/Guardian name (for YOUTH participant)
20. YOUTH participant:
22. What school does the participant attend?
23. Does the participant qualify for free or reduced lunch at school?

    1. Yes

    1. No
25. ADULT participant:
27. Please describe the financial need that requires fee assistance for this program.
29. ALL PARTICIPANTS:
31. Demographics

    The City of Roseville is committed to making our services available to all members of our community.We can only do that when we understand who is using them. to help us do that, please respond to the following demographic question. More than one box can be checked.

33. Which racial group(s) does the participant identify with?*

    1. American Indian / Alaska Native
    2. Asian

    1. Black/African American
    2. Hispanic or Latino origin

    1. Native Hawaiian or other Pacific Islander
    2. White/Caucasian

    1. Other race
    2. Choose not to self-identify
35. Does the participant have a sensory, physical or mental disability?*

    1. Yes

    1. No
37. SUPPORTING DOCUMENTS
    • First ensure you have scanned a copy of the participant's registration form and your proof of Roseville residency (such as a copy of your driver's license.
    • Then, in the field below, click "Browse" to navigate your computer to those scanned documents and upload them to this application form.

    
    

39. Upload scan of proof of ROSEVILLE RESIDENCY such as a driver's license*
41. Are there any recreational programs that are not currently offered that you would be interested in?
Leave This Blank:


43. 1. Receive an email copy of this form.
44. Email address

    This field is not part of the form submission.

45. Submit Submit and Print

* indicates a required field