Fee Assistance Application

Library and Recreation Department Fee Assistance Program
If you need assistance completing this form or need more information, please call (925) 931-5340 or email recreation@cityofpleasantonca.gov
Fee Assistance Scholarship Season
- Applicant's Name
  
  First NameLast Name
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Phone
  Format: (000) 000-0000.
- Email
  example@example.com
- Your Name
  
  First NameLast Name
- Date of Birth
  
  MonthDayYear
- Family #1
  
  First NameLast Name
- Date of Birth #1
  
  MonthDayYear
- Family #2
  
  First NameLast Name
- Date of Birth #2
  
  MonthDayYear
- Family #3
  
  First NameLast Name
- Date of Birth #3
  
  MonthDayYear
  Date
- Do you have any more family members to add?
- Family #4
  
  First NameLast Name
- Date of Birth #4
  
  MonthDayYear
- Family #5
  
  First NameLast Name
- Date of Birth #5
  
  MonthDayYear
- Family #6
  
  First NameLast Name
- Date of Birth #6
  
  MonthDayYear
- Family #7
  
  First NameLast Name
- Date of Birth #7
  
  MonthDayYear
- Signature of Applicant
- Date
  
  MonthDayYear
  Date
- Qualified applicants will be considered without regard to race, color, national origin, gender, age,medical condition, marital status, or religious belief. In accordance with the Americans with Disabilities Act (ADA), if special accommodations are necessary at any stage of the application process, please provide the Library and Recreation Department with advance notice
- Proof of Pleasanton Residency
  
  Other
- Please upload the file below:
  
  Cancelof
- Proof of Additional Assistance
  
  Other
- Please upload the file below
  
  Cancelof
Should be Empty:

Library and Recreation Department Fee Assistance Program