Youth Scholarship Program

Youth Scholarship Application

Tri-County Community Resource Center
This form is a request for financial assistance with the cost of youth activities (camps, lessons, field trips). Not all programs are eligible for assistance - please call our office at speak to a staff member at (352)507-4000 to confirm eligibility BEFORE COMPLETING THIS APPLICATION. Completing the form does not guarantee assistance - qualifications and limits apply. Only the parent or legal guardian may apply. This is not a program registration form; applicants who are approved for financial assistance will still need to contact the program provider directly to register their child for the activity.

ONCE YOU HAVE SUBMITTED THIS FORM, SOMEONE FROM OUR OFFICE WILL REACH OUT TO YOU WITHIN THREE (3) BUSINESS DAYS TO DISCUSS YOUR REQUEST.
Parent/Legal Caregiver's Name:*

First NameLast Name
Child's Name:*

First NameLast Name
Child's Date of Birth:*

MonthDayYear
Child's Race?*

Black or African American (non-Hispanic origin)White (non-Hispanic origin)Hispanic, Latino, or Spanish originAsianAmerican Indian or Alaska NativeMultiracialOtherPrefer not to Answer
Child's Gender?*

MaleFemaleTransgenderGender non-conforming/non-binaryPrefer not to Answer
Adult's Phone Number:*
Please enter a valid phone number.
Adult's Email:*
example@example.com
Physical Address (DO NOT PUT YOUR P.O. BOX):*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County of Residence (you and your child must reside in one of the counties below to qualify for this program):*

DixieGilchristLevy
What is your total monthly household income? Include the total combined income for all adults and children in the home, including employment, TANF, child support, disability, social security, or other income.*
Does your household currently participate in the SNAP/EBT program?*

YesNo
What is the name of the program you would like your child to attend?*
Should be Empty: