JCC Community Education

Jackson County Central Schools

PO Box 119

Jackson, MN  56143

Telephone (507) 847-6627  Fax (507) 847-3078

Opportunity Fund Scholarship Application

Goal: Ensure that all children who want to participate in community learning activities are able to participate regardless of financial ability. 

Applicant Name:  ________________________________ Age: _____  Grade: ____  Sex:  M   F

Address:__________________________________________________ Phone: ______________________

Parent(s) or Guardian:_________________________________  Phone: (H) __________ (W) __________

Address (if different):__________________________________________________

Referral (if applicable) by: ___________________________________ Phone: _________________

Background Information:

Jackson County School District Resident:  Yes    No                    Open Enrolled:   Yes    No

Number in Household: ________    Financial Need Indicated:  Yes    No

                (FREE or REDUCED School Lunch Application or Income Tax records may be requested)

Developmental Need (Please specify): _______________________________________________________

______________________________________________________________________________________

Other Circumstanced for Need (Please specify):________________________________________________

______________________________________________________________________________________

Describe Activity Cost Requested: __________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________

Amount you can pay:______________        

_____________________________________          ______________________________________

Participant Signature                                                           Parent/Guardian Signature

 This fund has been established through the generous donations from local service club organizations.

The board will determine eligibility and their will be a limit of funds available per household.

OFFICE USE ONLY: Total fee sponsored:___________________________                                                    Approx. Hours of Activity Provided: ___________

Skills/Assets Addressed by Activity:_______________________________________________________________