Section 1 of 1 in this document
Empowering Parents Grant Funds Request
Completion of this form does not guarantee registration or space in a program until a receipt for the program has been received.
You will be contacted via email for us to gather further information. Please allow us 48 hours during the work week to process requests.
Grant funds only cover those who are eligible under the funds.
Residency is based off of zip codes and those that pay utilities to the City of Pocatello.
ID Cards are not covered by the grant and will be an additional cost payable at the recreation desk.
If grant funds are denied, parents will be responsible for the class fee or registration will be terminated.
Parent Information
Name
First Name
*
Last Name
*
Address
Street Address
*
City
*
State
*
Zip
*
Cell Phone Number
*
Email Address
*
Children Information
Child #1 Name
First Name
*
Last Name
*
Child #1 Date of Birth
*
Child #1 Program(s) of Interest (check all that apply)
Dance Classes
Group Swim Lessons
Private Swim Lessons
Recreation Center Membership
Team Sports
Child #2 Name
First Name
Last Name
Child #2 Date of Birth
Child #2 Program(s) of Interest (check all that apply)
Dance Classes
Group Swim Lessons
Private Swim Lessons
Recreation Center Membership
Team Sports
Child #3 Name
First Name
Last Name
Child #3 Date of Birth
Child #3 Program(s) of Interest (check all that apply)
Dance Classes
Group Swim Lessons
Private Swim Lessons
Recreation Center Membership
Team Sports
Child #4 Name
First Name
Last Name
Child #4 Date of Birth
Child #4 Program(s) of Interest (check all that apply)
Dance Classes
Group Swim Lessons
Private Swim Lessons
Recreation Center Membership
Team Sports
Child #5 Name
First Name
Last Name
Child #5 Date of Birth
Child #5 Program(s) of Interest (check all that apply)
Dance Classes
Group Swim Lessons
Private Swim Lessons
Recreation Center Membership
Team Sports
Child #6 Name
First Name
Last Name
Child #6 Date of Birth
Child #6 Program(s) of Interest (check all that apply)
Dance Classes
Group Swim Lessons
Private Swim Lessons
Recreation Center Membership
Team Sports
disregard this