LMHS Youth League Scholarship Application

Youth League Scholarship Information

Licking Memorial Health Systems (LMHS) provides registration fee scholarships to children who, without this financial assistance, might not be able to participate in one of Licking County’s youth recreational athletic leagues. The LMHS Youth League Scholarship program provides opportunities for area youth to participate in recreational team sports as part of our mission to improve the health of the community. Participation in recreational team sports provides physical, mental, and character-building benefits.

Currently, LMHS Youth League Scholarships are being offered for, but not limited to, the following leagues:

AYSO Soccer
Buckeye Valley Family YMCA Leagues
Granville Recreational District
Heath Sertoma Youth Athletic Association
Johnstown Youth Athletic Association
Lakewood Youth Baseball Association
Lakewood Youth Softball Association
Licking County Sports Association
Licking Heights Youth Association
Licking Valley Youth Biddy Football League
Licking Valley Youth Sports Association
Miller Park Diamond Association

Mound City Little League & Softball
Newark Area Soccer Association
Newark Ice Hockey Association
North Fork Youth Athletic Association
North Newark Little League
Northridge Youth Athletic Association
Pataskala Parks and Recreation Programs
St. Louisville Youth Leagues
Southwest Licking Youth Baseball League
Southwest Licking Youth Association, LLC
Summit Station Licking Heights Youth Football Association
Upward Basketball
Utica Youth Athletics
Watkins Youth Softball

If you have any questions or need assistance completing the LMHS Youth League Scholarship application, please call the Development Department at (220) 564-4102, Monday through Friday, from 8:00 a.m. to 4:30 p.m.

Eligibility

To be eligible for the LMHS Youth League Scholarship program:

Athlete must be a Licking County resident.
Athlete must be age 15 or younger.
Household income must not exceed 250 percent of the federal poverty income guidelines.
Athlete participates in a minimum of 80 percent of the scheduled practices and games.
Participation by a family member in at least one (1) volunteer opportunity during the scholarship season.
Athlete or parent must have completed the youth league’s registration form.
Application must be completed by a parent, guardian, or head of household, with all requested information provided.

Please provide the total gross income for the 3 months and 12 months immediately preceding the date for which assistance is required. This must include income for everyone living in the home. Write the total gross income in the space provided on the application on the next page. Self-employed applicants must provide gross income, less reasonable business expenses. Personal expenses are not permitted.

Proof of income is required. Examples of acceptable income verification include:

Check stubs for 3 and 12 months
Documentation of Social Security, unemployment compensation, alimony, child support or pensions

If the household earned $0 income, please complete the voucher on page 4 of this application.

Option 1: Download, Print and Mail in Application

Click here to download the Youth League Scholarship Application (PDF)

Please return the completed application to:

Licking Memorial Hospital
Development Department
1320 West Main Street
Newark, Ohio 43055

Option 2: Complete Application Form Online

Please complete the following form in its entirety.

For suggestions on local leagues for which the scholarship may be applicable, please visit the Sports Activity Resources page.

If you have any questions or need assistance completing the LMHS Youth League Scholarship application, please call the Development Department at (220) 564-4102, from 8:00 a.m. to 4:30 p.m., Monday through Friday.


Athlete's Name:
Age:
Date of Birth:
Gender:	Male Female
Street Address:
Address Line 2:
City:
State:
Zip Code:
School Athlete Attends:
Grade:
Athlete Lives With:	Both ParentsFatherMotherOther
Requested Scholarship Amount:
Partial:
Season for Scholarship request:
Season Year:
League/Sport for Scholarship:
Has athlete ever received scholarships?:
If yes, please list resource and year:
Father's Name:
Occupation:
Home Phone:	( ) - Second part Third part
Work Phone:	( ) - Second part Third part
E-Mail Address:
Mother's Name:
Occupation:
Home Phone:	( ) - Second part Third part
Work Phone:	( ) - Second part Third part
E-Mail Address:
Guardian's Name:
Occupation:
Home Phone:	( ) - Second part Third part
Work Phone:	( ) - Second part Third part
E-Mail Address:

Please provide the following information for all of the members of the household - include everyone living in the home. Provide gross family income for the past 3 months and the past 12 months. Include income from employment, Social Security (SS), Supplemental Security Income (SSI), unemployment compensation, alimony, child support and pensions.

Name	Birthdate	Relationship to athlete	Gross income for past 3 months	Gross income for past 12 months
Household Member 1:		Household Member 1 Date of Birth:		Household Member 1 Relationship:	Household Member 1 Income Past 3 Months:	Household Member 1 Income Past 12 Months:
Household Member 2:		Household Member 2 Date of Birth:		Household Member 2 Relationship:	Household Member 2 Income Past 3 Months:	Household Member 2 Income Past 12 Months:
Household Member 3:		Household Member 3 Date of Birth:		Household Member 3 Relationship:	Household Member 3 Income Past 3 Months:	Household Member 3 Income Past 12 Months:
Household Member 4:		Household Member 4 Date Of Birth:		Household Member 4 Relationship:	Household Member 4 Income Past 3 Months:	Household Member 4 Income Past 12 Months:
Household Member 5:		Household Member 5 Date of Birth:		Household Member 5 Relationship:	Household Member 5 Income Past 3 Months:	Household Member 5 Income Past 12 Months:
Total persons in household:	Total persons in household:		Total family income:	Total Family Income for Past 3 Months:	Total Family Income for Past 12 Months:

Terms and agreements:

I understand that my signature authorizes LMHS to obtain verification of all information on this application and that additional information may be necessary for approval. I certify that all of the information on this form is true and correct. I understand that my child/children’s participation in this program requires a commitment to attend a minimum of 80% of the scheduled practices and games.

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