KICK Summer Camp Scholarship Application
Application to apply for a scholarship for your child – complete this form and return it to Kirkwood Community College – Continuing Education. Please
attach your child’s KICK camp registration form to this scholarship application. If you need help or have questions, please contact Jerilyn Garnant at
319-398-5529.
Part 1 – Child’s Name
Last
First
Date of Birth
Grade Entering
Camp Attending
Camp Section #
Camp Tuition
Part 2 – Monthly Income
Names of all adults living in the
home and anyone earning income
Name: Last, First
Check if No
Income
List all income received last month on the same line with the person who received it. You must list gross income (before taxes).
Age
Other Monthly
Income:
Gross Wages (before taxes)
I am paid this amount
Weekly
Every 2 Weeks
Pension, Welfare,
Retirement, Child
Support
Twice Per Month
Once per Month
Part 3 – Household Size Please list the number of children under age 18 in the household:
Part 4 – Certification and Signature
Required of all applicants: I certify (promise) that all information on this application is true and that all income is reported if required. I
understand that I will receive benefits from state funds based on information I give. I understand that officials may verify (check) the
information. I understand that if I give false information, my child may lose the scholarship benefit and I may be prosecuted.
A letter from your child’s school or Dept. of Food and Nutrition stating that your child is eligible for free and reduced meals benefits is
acceptable. Please attach a copy of this letter to your child’s scholarship application.
Signature of Parent or Guardian
Part 5 – Parent or Guardian Information
Name
Phone Contact
_
_
Street Address
City/State/Zip
_
Date
_
_
KCC – CE OFFICE USE ONLY – do not write in this section
Food Assistance or FIP
Eligibility Determination:
Total Income
Scholarship
Per:
Denied due to:
Week,
Every 2 Weeks,
Over income limits
Determining Official’s Signature
Date
Confirming Official’s Signature
Date
Follow-up Official’s Signature
Effective Date
Date
Twice A Month,
No fund available
Month,
Year
_
_
Important things to know.
Scholarships are available on a first come, first serve basis. Scholarships are limited to one per child.
1. A scholarship application is required for every child per camp. To apply for a scholarship, please fill out the
application as soon as possible.
2. Fill out one application per camp, per child.
3. Please answer all questions on the form.
4. Sign the form and return it to Kirkwood Community College – Continuing Education.
5. Notification – within approximately 10 working days after your scholarship application is received you will be sent a
letter telling you whether or not your student will receive a scholarship.
6. Your child’s registration for the camp will be processed after scholarship eligibility is determined.
Application can be returned to: Kirkwood Community College, Continuing Education
P.O. Box 2068
6301 Kirkwood Blvd., SW, Cedar Rapids, IA 52406
Like help with your application?
If you have questions or need help filling out the form, call Jerilyn Garnant at 319-398-5529. We provide confidential help.
Income Eligibility Guidelines
Parents: If your total household income is within the limits listed below, your child may be eligible for a camp
scholarship. Complete parts 1, 2 and 3 on the application. Return to KCCE – CE.
Household Size
1
2
3
4
5
6
7
8
Yearly
Monthly
Twice a Month
Every two weeks
Weekly
23,540
31,860
40,180
48,500
56,820
65,140
73,460
81,780
1,962
2,655
3,348
4,042
4,735
5,428
6,122
6,815
981
1,328
1,674
2,021
2,368
2,714
3,061
3,408
905
1,225
1,545
1,865
2,185
2,505
2,825
3,145
453
613
773
933
1,093
1,253
1,413
1,573
What should be reported as income?
Monthly Income:
List the income (BEFORE deductions) each person received last month and where it is from, such as wages, retirement, or welfare. (Part 2) If you have a
household member for whom last month’s income was higher or lower than usual, list an average monthly income by taking the income of the last several
months and dividing it by the number of months. Kirkwood CE has the right to request verification of the information you supply at any time. Purposeful
misrepresentation is subject to prosecution.
Types of income to report:
Wages
Pensions
Public Assistance
Alimony
Annuities
Child support payments
Strike benefits
Supplemental security income
Salaries
Unemployment compensation
Social security benefits
Interest
Tips
Workmen’s compensation
Disability income
Welfare payments
Commissions
Veteran’s subsistence benefits
Retirement income
Cash withdrawals from savings,
investments or trusts
Do not report income from:
Educational benefits
Scholarships
Babysitting
Shoveling
Grass Cutting
Food Stamps
What if my income is not always the same?
List the amount you typically earn. For example, if you generally earn $1000 each month, but you missed some work last month and only earned $900,
write down that you earn $1000 per month. If you routinely work overtime, include it, but do not include overtime if you work it occasionally.
Will the information I give on my application be checked?
Yes, we may ask you to send written proof.