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2. 
4. Please check what you are applying for*

   1. LPR Program

   1. Liberty Community Center Membership
6. First Name*
7. Last Name*
9. Address1*
11. City*
12. State*
13. Zip*
15. Home/Cell Phone #*
16. Work Phone #
18. Email Address*
20. Child(ren)'s Name
22. Name*
23. Date of Birth*
25. Name
26. Date of Birth
28. Name
29. Date of Birth
31. Name
32. Date of Birth
34. Name
35. Date of Birth
37. Copy of Child(ren)'s Birth Certificate
    Please attach a copy of children’s birth certificate if last name is different from applicants or court documentation showing legal guardianship
39. Qualifier for Scholarships
41. Primary Qualifier
    Families with children in the Liberty School District system that currently qualify for the school lunch program would qualify to apply for youth activities and/or Liberty Community Center memberships (where the youth is included). The application is valid for one year and must be renewed annually with the current school year’s approval letter provided. Families qualifying for reduced lunches will receive a 50% discount. Families qualifying for free lunches will receive a 75% discount (School approval letter/paperwork is required with application):
43. Secondary Qualifier
    Families with children living in the Liberty School District but not attending school may use Federal food stamp program, Medicaid and/or WIC as a qualifier for assistance. (Documentation is required with application)
45. School Approval Letter
    Please attach your approval letter from the Liberty School District that you currently qualify for the school lunch program
46. Federal Food Stamp Program
    Please attach your Medicaid and/or WIC documentation
48. Note
50. - For Liberty Community Center family memberships, recipient must qualify according to the Liberty Community Center family membership definition and membership includes the youth. Check membership requested:
52. Liberty Community Center Memberships

    1. Annual Family
    2. Summer Family

    1. Annual Youth
    2. Summer Youth

    Please select the membership you wish to apply for
54. Membership Info
    Learn more about memberships»

56. - For youth activities, each child under the age of 18 in a qualifying family may receive assistance up to four times during the year.

58. - Please allow 10 business days for the approval process and notification once all documentation has been received by the Liberty Parks & Rec Department.
60. - This request will be reviewed confidentially. By submitting this form, I am requesting assistance from the Liberty Parks & Rec Foundation due to my personal circumstances and I certify that all information provided is correct.
62. Confidentiality
    The Liberty Parks & Rec Department will use application information only for approval of a scholarship assistance request. Strict confidentiality will be maintained at all times during the decision process. Program leaders will not be informed of a participant’s scholarship status.
64. The Liberty Parks & Rec Foundation (LPRF) is a 501 (c)(3) charitable organization governed by an appointed board committed to supporting the mission and funding needs for the City of Liberty Parks & Rec programs and services.
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66. 1. Receive an email copy of this form.
67. Email address

    This field is not part of the form submission.

68. Submit

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