SCC 4-H Program Fee Waiver Application

✻ = Required

Santa Clara County 4-H Youth Development Program

Financial Assistance Application for Annual 4-H Enrollment Fees

Confidential

Provisions will be made to cover the Annual 4-H Enrollment Fees for eligible youth who are unable to pay them. The parent/guardian of an eligible youth must complete and e-sign this form.

For additional information, please contact: Susan Weaver, 4-H Program Representative @ sjweaver@ucanr.edu or 408-282-3119

If you are NOT applying for an enrollment fee waiver and are looking for the application for Event Financial Aid, please follow this link: http://ucanr.edu/survey/survey.cfm?surveynumber=22166

I am applying for the following type of Financial Aid: ✻

Annual 4-H Club Enrollment Fee Waiver

Dollar Amount Requested - Up to 100% enrollment waiver may be requested ✻

Youth Member's First Name: ✻

Youth Member's Last Name: ✻

Ethnicity:

(ANR NONDISCRIMINATION AND AFFIRMATIVE ACTION POLICY STATEMENT FOR UNIVERSITY OF CALIFORNIA EDUCATIONAL PROGRAMS May, 2015. It is the policy of the University of California (UC) and the UC Division of Agriculture & Natural Resources not to engage in discrimination against or harassment of any person in any of its programs or activities (Complete nondiscrimination policy statement can be found at http://ucanr.edu/sites/anrstaff/files/215244.pdf ) Inquiries regarding ANR’s nondiscrimination policies may be directed to John I. Sims, Affirmative Action Compliance Officer/Title IX Officer, University of California, Agriculture and Natural Resources, 2801 Second Street, Davis, CA 95618, (530) 750- 1397.) ✻

American Indian or Alaskan Native Asian Black Hispanic Native Hawaiian or Pacific Islander White Prefer not to state

Parent's First and Last Name: ✻

Parent Phone #: ✻

Family Email Address ✻

4-H Club Name: ✻

To determine eligibility for a reduction of the fee, please indicate if:

Monthly household cash income is at or below 185% of the Federal Poverty guidelines. If your child is eligible for/enrolled in free or reduced price school breakfast or lunch you meet this criteria.

(Reference: http://www.fns.usda.gov/cnd/governance/notices/iegs/iegs.htm) ✻

Yes No

Comments or any other information you wish to share:

I do hereby confirm that the above information is accurate. Parents Name: ✻

UC reserves the right to verify the above information by further reviewing the household financial status with the parent/guardian.