Monon Community Center Scholarship Program

Monon Community Center
Scholarship Program
General Information
Carmel Clay Parks & Recreation (CCPR) seeks to provide opportunities for all to participate in programs and
wellness activities by providing scholarships, both funded and subsidized.
1. Need is the primary criterion upon which scholarships are considered. The Federal School Lunch
Program Standards will be used as a guideline.
2. Scholarships will be awarded in the amounts of 75%, 50%, or 25% of the published fees. Accepted program
participants are expected to pay at least 25% of the registration fee. No full program/pass scholarships will be
awarded.
3. Scholarships are not guaranteed and are available on an as-needed basis.
4. CCPR cannot provide scholarships for programs when primary costs are contractual (such as trips or
performances, tickets or admissions).
5. Scholarships are not available for late fees.
6. CCPR reserves the right to limit the amount of scholarships awarded to an individual/family annually, particularly if
the demand for scholarships by the community is high. No family will be awarded more than $500 per calendar year
for recreation programs and/or the cost of a household annual membership in passes. Cap amount does not include
ESE or Summer Camp scholarships.
7. All monthly scholarship fees must be paid on time. In the event of a declined payment, the scholarship
recipient’s pass will be cancelled. A new scholarship application may be submitted one year from original
scholarship award date. Any outstanding balances with CCPR must be paid prior to consideration.
8. Approval of any scholarship application does not automatically register that person into the program or
membership of choice. Registration for any program is the responsibility of the family requesting assistance.
All payments must be received by CPPR prior to registration deadlines and participation.
9. Scholarship applications will be accepted up until two weeks prior to the program start date.
10. CCPR reserves the right to revoke scholarships for cause. In the event of scholarship revocation, outstanding
balances for programs or facilities used will be placed on the household account and are due immediately.
11. Confidentiality: All information provided will only be used to determine the level of scholarship awarded.
ELIGIBILITY
• City of Carmel or Clay Township residency required with proof of residency (current utility bill,
housing lease, etc.) -must be primary residence of participant/household.
• Proof of Income – All applicants must provide most recent IRS 1040 tax form. Form must be for previous
st
calendar year. Forms from two years previous will be accepted until March 1 .
APPLICATION PROCESS
• Complete the Scholarship Application Form (one form per applicant/membership, one set of supporting info per
family please). All information requested must be supplied. Incomplete forms will not be considered.
Applications and attachments should be submitted to:
Carmel Clay Parks & Recreation
Attn: Scholarships
1235 Central Park Dr. E
Carmel, IN 46032
Email: [email protected]
Please note “Scholarships” in the subject line.
All information submitted will be kept confidential.
Monon Community Center
Scholarship Program
Eligibility Guidelines
2016 Federal Poverty Guidelines (FPG)
Monthly Income Levels (from 100% to 185% of FPG)
75%
Scholarship
50%
Scholarship
25%
Scholarship
FPG (125%)
Monthly
Income
FPG (150%)
Monthly
Income
FPG (185%)
Monthly
Income
1
$1,237.50
$1,485.00
$1,831.50
2
$1,668.75
$2,002.50
$2,469.75
3
$2,100.00
$2,520.00
$3,108.00
4
$2,531.25
$3,037.50
$3,746.25
5
$2,962.50
$3,555.00
$4,384.50
6
$3,393.75
$4,072.50
$5,022.75
7
$3,826.04
$4,591.25
$5,662.54
8
$4,259.38
$5,111.25
$6,303.88
*
$433.33
$520.00
$641.33
Household
Size
*For households with more than 8 persons, add this amount for each additional person.
2016 Federal Poverty Guidelines (FPG) income levels are published in the
Federal Register, Vol. 81, No. 15, January 25, 2016, pp. 4036‐4037
All information submitted will be kept confidential.
Monon Community Center
Scholarship Program
A separate scholarship application form must be submitted for each program
participant/membership, and individual applications should be submitted a
minimum of two weeks prior to the requested program’s start date.
Applicant’s Name:
Age:
Address:
(Street)
(City)
(Zip)
Program/Pass Requested: _______________________________________________________________________
Parent/Guardian’s Name (if applicable):
Address (if different from above):
Phone (daytime):
Phone (evening):
Number of household members UNDER 18 years of age:____ Number of household members OVER 18 years of age:____
ELIGIBILITY CHECKLIST
Please include:
 Most recent IRS 1040
 Proof of in-city/township residency
 Completed application
 Signed Scholarship Agreement (one for each included family member)
 Completed Pass Registration Form and/or completed Program Registration Form
Please give a brief statement of reasons for applying for assistance:
Have you received a Carmel Clay Parks & Recreation Scholarship in the past?
If so, when?
I/We, the undersigned, understand that the information given will be kept confidential. The information provided
is true and complete to the best of my knowledge and belief. I consent to the disclosure of such information for
purposes of income and verification related to my/our application for financial assistance. I understand that any
willful misstatement of material fact will be grounds for disqualification. I agree to pay any outstanding
balance I have on my household account after all scholarship money has been applied.
Applicant’s Signature
All information submitted will remain confidential.
Date
Monon Community Center
Scholarship Program
Agreement
Carmel Clay Parks & Recreation is to consider awarding a scholarship in good faith to
___________________________________________.
Recipient’s Name
As a recipient of a scholarship, I agree to the following:
∗
∗
∗
∗
∗
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I will be on time to all classes and/or meetings.
I will participate to the fullest extent of my abilities in all activities included in my selected
program.
I and all pass holders on my membership will average at least one visit per week.
I will know and adhere to all CCPR rules.
I will be respectful of my instructors/staff, myself and other students in my program.
I will be a model of effort and behavior for other participants and patrons of CCPR.
I will make all monthly payments on time. I will make certain, as it is my responsibility,
to update payment information at least 7 days prior to payment due date.
I understand that if I fail to complete any of the above, my scholarship may be revoked and the
remaining balance will be due to CCPR.
_
_
_
Recipient’s Signature
_
Date
I, the parent/guardian of the above recipient, will do my best to make sure the scholarship
recipient adheres to and completes the requirements listed and understand that failure to
complete any of the above may result in the scholarship being revoked and the remaining
balance due to CCPR.
_
_
_
Guardian’s Signature
_______________________________________________________________
Signature of Approving Staff Member
All information submitted will be kept confidential.
Date
____________________
Date
Last Name:______________________ HH#:_____________ Healthways ID#:___________________
Staff Initials: ________
2016 Pass Registration Form
1. Payer Information:
2.
Date: ____/____/____
___
________________________________________/____________________________________________/_______________________________
PRIMARY GUARDIAN’S FIRST NAME
LAST NAME
BIRTHDATE
__________________________________________________/______________________________________/____________/______________
ADDRESS
or
HH #
CITY
STATE
ZIP CODE
____________________________________/________________________________________/_______________________________________
HOME PHONE
WORK PHONE
CELL PHONE
_____________________________________________________________/_____________________________ __________________________
E-MAIL ADDRESS
EMERGENCY CONTACT NAME/PHONE
____ Modifications (check if needed). See “Statement of Accessibility” on reverse side of this form.
____ I have read and fully understand the policies and the Carmel Clay Parks & Recreation Waiver and Release on page 2 of this form. I
understand my signature, or my primary guardian’s signature if I am under 18, is required to use the Carmel Clay Parks & Recreation facility.
____________________________________________________________________________________/________________________________
PRIMARY GUARDIAN’S SIGNATURE
DATE
2. Participant Information (Proof of residency may be required for all adult household members):
PASSHOLDER (FIRST & LAST NAMES)
BIRTHDATE
/
/
/
/
/
/
/
/
/
/
/
/
GENDER
*First month payment must be included with this registration form.
First month payment made today by:
Cash
Check
VISA/MasterCard/American Express/Discover
PASS TYPE
MONTHLY FEE
Total Amount Due Today:
Gift Card
$_________________
3. Payment Information:
PAYMENT
1.) One Time Payment (Annual Passes Only):
Amount Paid Today
$______________
First month payment made today by:
Cash
Check
Visa/MasterCard/AmEx/Discover
Gift Card
Initial
2.) Automatic Monthly Payment required for future payments:
Payment amount authorized for processing each month
$_________________
Visa/MasterCard/AmEx/Discover
Checking/Savings Debit
(Must attach voided check)
*Complete appropriate boxes below.
By completing a box below, I authorize Carmel Clay Parks & Recreation to process payment (s) indicated for my Pass(es) to the Monon
Community Center. I will provide the Carmel Clay Parks & Recreation Department a minimum cancellation notice of 7 days prior to the next
payment date.
Credit Card Information
*Card must be swiped at time of purchase or may be phoned in for payment.
_____________________________
EXP. DATE (mm/yy)
ACCOUNT NUMBER- please fill in first 4, last 4
___________________________________________________________/_________________________________________________________
CARDHOLDER NAME (Please Print)
AUTHORIZED SIGNATURE
Checking/Savings Debit Information *Voided check or account verification from financial institution must be attached.
____________________________________________________________/_______________________________________________/________________________________________________
FINANCIAL INSTITUTION
ROUTING NUMBER
ACCOUNT NUMBER
______________________________________________________________________/_____________________________________________________________________________________
NAME ON ACCOUNT (Please Print)
AUTHORIZED SIGNATURE
1235 Central Park Drive East, Carmel, IN 46032 | 317.848.7275 | InTrac: 711 | carmelclayparks.com
MSS: ________
Date: __/__/__
Pass Registration Form Page 2
Carmel Clay Parks & Recreation Waiver and Release
On my behalf and on behalf of my heirs and assigns, I HEREBY RELEASE, WAIVE, DISCHARGE, COVENANT NOT TO SUE AND AGREE TO HOLD HARMLESS THE CARMEL/CLAY BOARD OF PARKS
AND RECREATION, CARMEL CLAY PARKS & RECREATION, CITY OF CARMEL, CLAY TOWNSHIP, ITS AND THEIR OFFICIALS, OFFICERS, PASSHOLDERS, INDEPENDENT CONTRACTORS, EMPLOYEES
AND VOLUNTEERS (the “Releasees”), from any and all claims or liability for personal injury or property damage my child and/or I may cause or suffer directly or indirectly arising out of or
relating in any respect to participation in a program, event, service or facility provided by or made available through Carmel Clay Parks & Recreation. This waiver and release of all claims,
demands, actions, and liability shall include, without limitations, any injury, damage or loss to person or property which may be (a) caused by any act, or failure to act, by Releasees even if said
injury, damage or loss results from the negligence of any or all of the above-identified Releasees or (b) sustained by me during and/or at the Carmel Clay Parks & Recreation program, event,
service or facility in which I and/or my child participate(s).
Photo and Video Policy
Photos and video are periodically taken of participants in a class, during an event, or within Carmel Clay parks and facilities. Photos and video footage are for the use of Carmel Clay Parks &
Recreation and may be used in the Department’s publications, website, and social media. All photos are the property of the Carmel/Clay Board of Parks and Recreation. For more information,
please contact the Marketing Director at 317.573.4020 or [email protected]. By signing this registration form, I understand and acknowledge my photo and the other participants
listed may be utilized in marketing materials for the Department.
Carmel Clay Parks & Recreation reserves the right, at its sole discretion, to withhold and/or withdraw permission to photograph on its premises or to reproduce photographs of objects in its
collections. Please follow our photo shoot process and submit the Photo Shoot Application available at http://carmelclayparks.com/policies/.
Statement of Accessibility
CCPR believes every individual has the right to participate in activities and programs that supports their physical, mental, social and emotional wellness, and therefore contribute to enhancing
their overall quality of life. This is achieved by identifying and removing barriers to serve individual and community needs, in addition to providing accessible quality programs and services to
all. Please indicate on the registration form if any modifications are needed for successful inclusion into a program or service in accordance with the Americans with Disabilities Act (ADA).
Code of Conduct
All users of facilities are expected to exhibit appropriate behavior at all times will participating, spectating or attending any program, event, service and/or facility provided by Carmel Clay
Parks & Recreation. This includes in programs, events, services or facilities that may or may not require an admission fee, spectating at athletic events, concerts or attending special events. The
following guidelines are designed to provide safe and enjoyable facilities for all users. Users shall:
• Show respect to all users and facility staff/supervisors.
• Take direction from facility staff/supervisors.
• Refrain from using abusive or foul language.
• Refrain from causing bodily harm to self, other users or facility staff/supervisors.
• Refrain from damaging equipment, supplies and facilities.
A written or verbal warning shall be given to users/spectators if the Code of Conduct rules have been violated. If there is a second occurrence, users/spectators shall be withdrawn from the
facility without a refund.
Monon Community Center Pass
Membership provides complete access during regular hours of operation to the Waterpark (seasonal), Indoor Aquatics, Fitness Center, Track, Gymnasium (during open gym times as specified
on gym calendar), KidZone (childcare), and Group Fitness Classes (Excluding Wellness). Passes do not include participation in swim lessons and structured recreation or sports programs.
KidZone
KidZone (childcare) is available to children 6 months to 12 years for up to a maximum of two hours per visit. Parent(s) or guardian(s) must remain in the MCC during the time of visit.
Reservations are recommended, drop-ins will be accommodated on a first-come, first-served basis as long as the staff-to-child ratios remain within the 1:12 guidelines.
Aquatic Seasonal Pass
The aquatics seasonal pass is available for seasonal purchase (Saturday of Memorial weekend through Labor Day).
Age Definition and Fitness Center Requirements
A Youth is defined as an individual, 3 to 15-years-old. Children age 2 and under are admitted free when accompanied by an adult. Youth must be at least 11 years to use the fitness center.
Youth ages 11-15 must complete orientation before using the fitness center. Youth ages 11-13 must be accompanied and directly supervised by an adult member while using the Fitness
Center. An Adult is defined as an individual, 16 to 64-years-old. A Senior is defined as an individual, 65-years-old and older.
Declined Auto Payments/Returned Checks
Declined monthly payments and/or returned checks will result in cancellation of pass privileges and participation in department programs and services until delinquent fees are paid in full.
Monthly passes must have current billing information on file. It is the responsibility of consumer to keep the Monon Community Center updated of any changes to their billing method so that
funds may be withdrawn monthly.
Pass Refund Policy
The issuance of refund checks is subject to the Indiana State Board of Account’s claim procedures and may take 3-4 weeks to process. Purchases made by use of credit/debit card may be
refunded directly to the card. PLEASE SEE BELOW FOR SPECIFIC PASS REFUND ELIGIBILITY.
Pass Cancellation Policies
Monthly Pass
Automatic payment setup is required from a credit/debit card, or checking or savings account for a Monthly Pass. Monthly Passes shall remain in full effect until cancelled by the account
holder or by Carmel Clay Parks & Recreation. Cancellation requests must be received in writing or online at least seven (7) business days before the next automatic payment date to stop the
payment from being processed. All associated passes shall be cancelled effective the date the written cancelation notice is received. Prorated refunds shall not be issued for Monthly Passes.
Annual Pass
Annual passes shall remain in full effect for one year from the date of purchase. Early cancellation requests must be received in writing. All associated passes shall be cancelled effective the
date the written cancellation is received. A prorated refund shall be issued based on the number of full months remaining on the pass based on the date the cancellation request is received.
Seasonal Pass
Seasonal passes shall remain in full effect from the Saturday before Memorial Day through Labor Day. Prorated rates are not available based on the date of purchase. Early cancellation
requests must be received in writing. All associated passes shall be cancelled effective the date the written cancellation is received. A prorated refund shall be issued based on the number of
full months remaining on the pass based on the date the cancellation request is received.
Pass Transfer Policy
Requests to transfer to a different pass type must be received in writing. Pass transfer requests require a minimum of seven business days’ notice prior to the next billing date, which allows
time for CCPR to update the auto payment processing setup.
Form revised 12/14/15
1235 Central Park Drive East, Carmel, IN 46032 | 317.848.7275 | InTrac: 711 | carmelclayparks.com