IN YOUR SHOES (IYS)
Sports & Activity Scholarship Application
General Program Information
In Clinton County, childhood obesity and poverty rates are higher than national averages. The In Your Shoes
program was developed to reduce childhood obesity rates in Clinton County by encouraging physical activity and
participation in extracurricular sports and activities. The purpose of the In Your Shoes program is to promote
physical activity, teamwork, volunteerism and leadership through funding extracurricular sports and activities for
children in Clinton County.
In Your Shoes pays for the registration fees and equipment needed for approved applicants to participate in
extracurricular sports and activities. As a condition of accepting this award, each student must complete 10 hours
of volunteer work in the community. Volunteer work can be done with IYS, the extracurricular organization, the
United Way, or any other charitable organization within Clinton County, PA. The In Your Shoes Sports & Activity
Scholarship Applications are valid for 1 school year for a maximum award of up to $175 per student. All fees are
paid directly to the extracurricular organization for registration fees and all equipment you request from IYS will be
provided by In Your Shoes. No money will be paid to any parent or child directly, and no refunds will be issued for
payments made to the organization prior to approval.
Requirements
To be eligible for a scholarship, each child must:
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Attend a school in the KCSD or reside in Clinton County, PA
Be registered or plan to register for an organized sport or extracurricular activity. Completing this application
DOES NOT register the participant in the activity.
Be between the ages of 5 and 18 at the time of application.
Agree to do 10 hours of volunteer work in the community.
Determination of Eligibility
Priority may be given to youth proving to meet one or more of the following criteria:
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Receiving assistance from programs such as: Food Stamps, Medicaid, Free/Reduced Lunch
Children Living in Foster Care or Government Housing
Disabled Children
Families suffering from a recent tragic event or an immediate financial hardship
Body Mass Index measurement above the 85th percentile with documentation signed by the school nurse or
family physician
Families with multiple children involved in multiple activities
Written recommendations by school representatives, Clinton County Children & Youth or other social service
representatives
First time applicants meeting any of the above criteria
Prior participants meeting any of the above criteria who have completed their volunteer hours with IYS
Important to Know
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Any organized youth sport or activity in Clinton County can be funded by an IYS scholarship.
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Meeting the above criteria DOES NOT guarantee that you will be awarded funding from In Your Shoes. All
scholarships will be awarded based on demonstrated need, available funding and meeting all
deadline/application requirements.
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Approval one year DOES NOT guarantee approval every year. A new application is required to be completed
each school year for each student.
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Scholarships are limited to 3 awards per family/per address per year provided that funds are available and
requirements are fulfilled.
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If you receive funding from IYS for an activity and you quit that activity, you must notify IYS within 7 days and
return all purchased equipment. Quitting an activity may reflect negatively on the status of your future IYS
applications, especially if you fail to notify us and/or to return any equipment that was purchased or issued by
In Your Shoes.
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Failure to complete your volunteer hours or to return your volunteer log to IYS will lead to a denial of all future
applications until those hours are completed and submitted to IYS.
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Approval of a scholarship DOES NOT register the participant in the activity. You must contact the
extracurricular organization to get registered for the desired sport or activity. Fees are paid directly to the
organization where the student is registered.
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To have payments and equipment delivered on time, contact IYS at least 2 weeks prior to each registration
event and when your equipment is needed.
To Apply
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Fully and accurately complete the IYS Sports & Activity Scholarship Application
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Read, sign and submit the IYS Rules & Responsibilities Agreement
Submit documents that prove eligibility (i.e. pay stubs, Medical Assistance, UC, BMI results, referral letter, etc.)
Return the Application, the Agreement and the Eligibility Documents to In Your Shoes at PO Box 367, McElhattan,
PA 17748 at least 2 weeks prior to activity.
Call IYS at 570-295-1293 at least 2 weeks in advance to request cleats or any other needed equipment.
For prior IYS Participants:
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Your Volunteer Log from the previous year(s) must be completed and submitted to IYS before a new application for
funding will be considered. If you have not already done so, include your Volunteer Log with this application.
For more information, call IN YOUR SHOES at 570-295-1293.
IN YOUR SHOES AWARD APPLICATION
Contact
Contact
Information
Information
Student’s Name:
Age:
Height:
Required
School:
Weight:
Required
Parent or Guardian’s Name
Street Address
City, State, Zip
Phone (Home and Cell)
E-Mail Address
Availability
Acceptance of this grant from In Your Shoes requires student commitment to volunteerism. For each grant awarded,
the student/parent must complete ten (10) volunteer hours with In Your Shoes or the extracurricular
organization.
____ Student’s Initials
____ Parent’s Initials
Are you able to fulfill these volunteer requirements?
______Yes
______No
Where will you do your volunteer work?
_____In Your Shoes
_____Participating Athletic Organization
_____Another Community Organization
Would you like to receive calls, texts or emails regarding volunteer opportunities with IYS or the
CC United Way?
_____Yes
_____No
_____Call _____Text _____Email
Interests
Tell us in which activity you would like to participate.
___ Football
Youth or MS/HS
___ Basketball Youth or MS/HS
___ Baseball League?______________________
___ Wrestling MatTown or MS/HS
___ Softball League?______________________
___ Bandfront
___ Cheerleading Youth or MS/HS
___ Other (Please specify):
Has the student participated in this activity in the past?
____YES
____ NO
Has the student ever quit this or any other activity?
____YES
____ NO
Has this student ever received funding from IYS?
____YES
____ NO
What are the required fees for participation in this activity?
________________________________________
When and where does payment need to be sent?__________________________________________________
What equipment do you need IYS to provide for this activity?_______________________________________
List sizes of cleats, shoes, pants, etc. needed. ____________________________________________________
Financial Qualifications
In Your Shoes grants funding for extracurricular sports and activities based on financial need. Please
submit the following information as it relates to your family size and your household income.
Please provide documentation (copy of pay stubs, W-2, tax returns, etc.) and send along
with application.
# of adults living in your household?
# of children living in your household?
How many family members contribute to your household income?
What is your total annual household income?
____
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____
____
Less than $10,000
$10,000-$15,000
$15,000-$20,000
$20,000-$25,000
____ $25,000-$30,000
____ $30,000-$35,000
____ $35,000-$40,000
____ $40,000-$45,000
____$45,000-$50,000
____ $50,000-$55,000
____ $55,000-$60,000
____ Greater than $60,000
Summarize
In a short paragraph, tell us why you should be granted funding from In Your Shoes for this activity.
Agreement and Signature
By submitting this application, I affirm that the facts set forth in it are true and complete. I understand
that if I am approved for funding, any false statements, omissions, or other misrepresentations made
by me on this application may result in immediate rejection of this application. In Your Shoes will
review applications and determine eligibility based on both the needs of the applicants and the
availability of In Your Shoes funding. Funds will be granted on a year-to-year basis, and your approval
is not guaranteed from year-to-year. Applications must be submitted each year. All participant
applications will be reviewed and all grant allocations will be determined by In Your Shoes.
Student’s Name (printed)
Student’s Signature
Date
Parent’s Name (printed)
Parent’s Signature
Date
Our Policy
It is the policy of this organization to provide equal opportunities without regard to race, color, religion,
national origin, gender, sexual preference, age, or disability.
Thank you for completing this application form and for your interest in In Your Shoes.
Please send completed application and proof of income to:
In Your Shoes
P.O. Box 367
McElhattan, PA 17748
In Your Shoes will contact you regarding your application status. Please allow 1-2 weeks for the
application review and approval.
If you have any questions regarding this application or your approval status, please contact Tammy Miller
at 570-295-1293.
TO BE COMPLETED BY IN YOUR SHOES STAFF MEMBERS ONLY
Reviewer (Printed Name)
Reviewer’s Signature
Date
Approval
Amount Awarded
Participating Organization
Date Payment Sent
____ Approved
____ Denied
Explain:
In Your Shoes Rules and Responsibilities Contract
Because I am accepting funding from In Your Shoes I understand the following:

I am required to complete 10 hours of volunteer work for the In Your Shoes program, for
another community organization (like a church, a fire dept. or the Clinton County United
Way) or for the participating extracurricular organizations for which I am approved.
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I understand that volunteer hours must be completed by the end of the school year in which
I am receiving funding and the form must be completed and returned to In Your Shoes.
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I understand that In Your Shoes is providing funding for registration fees and required
equipment only and any optional purchases would be my responsibility.
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I will obey all rules and fulfill all requirements required by the participating extracurricular
organization, including any fundraising requirements.
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I will notify the In Your Shoes organization within 7 days of quitting an In Your Shoes
funded activity to allow for In Your Shoes to collect any possible refunds; and I will return
any provided equipment.
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I understand that school and homework are my number one priorities, and I will strive to
maintain good grades and regular attendance.
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I understand that I must complete a new In Your Shoes application for each school year,
and I understand that funding is not guaranteed from year-to-year.
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I understand that the maximum annual award per student per school year is $175.
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In turn, In Your Shoes agrees to treat you with kindness and respect.
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In Your Shoes agrees to pay all registration fees and provide any required equipment.
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In Your Shoes agrees to maintain confidentiality of your application, your financial
information and any other information you disclose without your permission.
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In Your Shoes will not disclose your participation in the In Your Shoes program to anyone
outside of In Your Shoes and the participating extracurricular organization.
If I fail to abide by these rules, I understand that In Your Shoes can and will take away privileges as
appropriate, which may disqualify me from any future funding from In Your Shoes. By signing this
agreement, I certify that the information provided to In Your Shoes is true and accurate, and I agree to
fulfill all requirements as set forth in this contract.
Student’s signature
Date
_______________________________________________________________________________________________________________________________
Parent’s signature
Date
In Your Shoes Representative’s signature
Date