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2. The Recreation Activity Assistance Program is available to Palm Beach Gardens residents who have a demonstrated financial hardship that would prevent them from participating in childcare programs or an enrichment/fitness program for adults. For a complete understanding of the program, applicants are to familiarize themselves with the guidelines that set forth the program details. This application must be completely filled out for each assistance request.

4. Applicant (Parent) Information

6. Parent Legal First Name*
7. Parent Legal Last Name*
8. Parent Date of Birth*
10. Parent Contact Phone Number*
11. Parent Contact Email Address*
12. Length at Current Residence*
14. Current Street Address of Residence*
15. State*
16. Zip Code*
18. Attach Copy of Drivers License*
19. Attach copy of other agency-issued documents (FPL, Seacoast, Xfinity, cell phone, etc) that contains your name and PBG address.*
21. Choose One*

    1. Rent
    2. Own

    1. Other
22. If Other, please explain.
24. Spouse Legal First Name (if applicable)
25. Spouse Legal Last Name (if applicable)
27. Spouse Contact Phone Number
28. Spouse Email Address
29. Spouse Date of Birth

31. Assistance Requested Information

33. Is this request for assistance for:*

    1. Adults listed above

    1. Child / Children
34. Which program are you applying for assistance?*
36. What is the program fee?*
37. What portion of the program fee are you able to pay?*
39. Have you applied and/or receiving assistance for this program from another organization?*

    1. No
    2. Yes
40. If Yes, from who?
41. If Yes, attach verification.
43. Briefly explain why you are seeking assistance.*

45. Children Information

    Attach a birth certificate for each child. Skip if this application is not for children.

47. Child 1 First Name
48. Child 1 Last Name
49. Date of Birth
51. School Attending
52. Attach Birth Certificate
54. Relationship

    1. Parent
    2. Legal Guardian
    3. Grandparent

    1. Foster Parent
    2. Other
55. If Other, please explain.
57. Child 2 First Name
58. Child 2 Last Name
59. Date of Birth
61. School Attending
62. Attach Birth Certificate
64. Relationship

    1. Parent
    2. Legal Guardian
    3. Grandparent

    1. Foster Parent
    2. Other
65. If Other, please explain.
67. Child 3 First Name
68. Child 3 Last Name
69. Date of Birth
71. School Attending
72. Attach Birth Certificate
74. Relationship

    1. Parent
    2. Legal Guardian
    3. Grandparent

    1. Foster Parent
    2. Other
75. If Other, please explain.

77. Financial Need Verification

    List all assistance programs that you are currently eligible and receiving for you and/or your children. Attach approval verification for each. Financial need can be demonstrated if you qualify for County, State or Federal assistance programs.

79. Assistance Program 1
80. Attach Verification
82. Assistance Program 2
83. Attach Verification
85. Assistance Program 3
86. Attach Verification
88. Assistance Program 4
89. Attach Verification
91. Family gross taxable income for previous year:*
92. Attach last year's tax forms.*
94. Parent Current Employer*
95. Employer Address*
97. Spouse Current Employer
98. Spouse Employer Address
100. List any other income such as unemployment, alimony, child support, rental income, etc.

102. I have read and understand the guidelines that govern this program, and I have provided truthful and accurate information above to gain financial assistance from the City of Palm Beach Gardens.

104. Applicant Name
105. Date & Time
     Date & Time

     Date & Time
Leave This Blank:


107. 1. Receive an email copy of this form.
108. Email address

     This field is not part of the form submission.

109. Submit

* indicates a required field