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2. To qualify for assistance for City of Dubuque Leisure Services programs you must live within the city limits of Dubuque and meet the income requirements established by The Department of Housing and Urban Development (HUD). 

   Those who qualify for a Leisure Services Family Scholarship will automatically qualify for the Creative Adventure Lab scholarship program which includes a complimentary 1-year Family Play Membership ($180 value). Please note, the information you provide in this form will be shared with the Creative Adventure Lab.

4. Applicant Information
6. First Name
7. Last Name
9. Address1
11. Address2
13. City
14. State
15. Zip
17. Phone Number
18. Email Address
20. Income Verification
22. Including yourself, how many RELATED people are living in your household?*
    -- Select One --2345678 or more
24. Family Size 2: Select the range that shows the amount of your combined household income.*
    -- Select One --$0 – $21,000$21,001 – $35,000$35,001 – $56,000above $56,000
26. Family Size 3: Select the range that shows the amount of your combined household income.*
    -- Select One --$0 – $23,650$23,651 – $39,400$39,401 – $63,000above $63,000
28. Family Size 4: Select the range that shows the amount of your combined household income.*
    -- Select One --$0 – $26,250$26,251 – $43,750$43,751 – $70,000above $70,000
30. Family Size 5: Select the range that shows the amount of your combined household income.*
    -- Select One --$0 – $28,350$28,351 – $47,250$47,251 – $75,600above $75,600
32. Family Size 6: Select the range that shows the amount of your combined household income.*
    -- Select One --$0 – $30,450$30,451 – $50,75$50,751 – $81,200 above $81,200
34. Family Size 7: Select the range that shows the amount of your combined household income.*
    -- Select One --$0 – $32,550$32,551 – $54,250$54,251 – $86,800above $82,250
36. Family Size 8: Select the range that shows the amount of your combined household income.*
    -- Select One --$0 – $34,650 $34,651 – $57,750 $57,751 – $92,400above $92,400
38. Attention
    Return to Recreation Division website

    Your combined household income exceeds the income eligibility requirements and you do not qualify for assistance for Leisure Services programs. For questions, please contact the Leisure Services office at 563-589-4263. 

40. Is the participant from a home where there is a female head of household?*
    -- Select One --YesNo
42. Is the person you are applying for a member of a household using the Housing Choice Voucher (Section 8) rental assistance program?*
    -- Select One --YesNo
44. Is the person you are applying for a member of a household on the waiting list for the Housing Choice Voucher (Section 8) rental assistance program?*
    -- Select One --YesNo
46. Household Members

    Please provide the following information for yourself and the members of your household. Note, the gender, race, and ethnicity fields are optional. To provide the most equitable services possible, we would like to know more detailed information on who participates in our programs.

48. Person 1: Your Information

    Please enter your information in the Person 1 fields.

50. 1a. Name
51. 1b. Relationship
52. 1c. Date of Birth
54. 1d. Gender

    1. Male
    2. Female
    3. Other
55. 1e. Race

    1. White
    2. Black or African American
    3. Asian
    4. American Indian or Alaska Native
    5. Pacific Islander
    6. Other
56. 1f. Ethnicity

    1. Hispanic
    2. Non-Hispanic
58. Person 2
60. 2a. Name
61. 2b. Relationship
62. 2c. Date of Birth
64. 2d. Gender

    1. Male
    2. Female
    3. Other
65. 2e. Race

    1. White
    2. Black or African American
    3. Asian
    4. American Indian or Alaska Native
    5. Pacific Islander
    6. Other
66. 2f. Ethnicity

    1. Hispanic
    2. Non-Hispanic
68. Person 3
70. 3a. Name
71. 3b. Relationship
72. 3c. Date of Birth
74. 3d. Gender

    1. Male
    2. Female
    3. Other
75. 3e. Race

    1. White
    2. Black or African American
    3. Asian
    4. American Indian or Alaska Native
    5. Pacific Islander
    6. Other
76. 3f. Ethnicity

    1. Hispanic
    2. Non-Hispanic
78. Person 4
80. 4a. Name
81. 4b. Relationship
82. 4c. Date of Birth
84. 4d. Gender

    1. Male
    2. Female
    3. Other
85. 4e. Race

    1. White
    2. Black or African American
    3. Asian
    4. American Indian or Alaska Native
    5. Pacific Islander
    6. Other
86. 4f. Ethnicity

    1. Hispanic
    2. Non-Hispanic
88. Person 5
90. 5a. Name
91. 5b. Relationship
92. 5c. Date of Birth
94. 5d. Gender

    1. Male
    2. Female
95. 5e. Race

    1. White
    2. Black or African American
    3. Asian
    4. American Indian or Alaska Native
    5. Pacific Islander
    6. Other
96. 5f. Ethnicity

    1. Hispanic
    2. Non-Hispanic
98. Person 6
100. 6a. Name
101. 6b. Relationship
102. 6c. Date of Birth
104. 6d. Gender

     1. Male
     2. Female
     3. Other
105. 6e. Race

     1. White
     2. Black or African American
     3. Asian
     4. American Indian or Alaska Native
     5. Pacific Islander
     6. Other
106. 6f. Ethnicity

     1. Hispanic
     2. Non-Hispanic
108. Person 7
110. 7a. Name
111. 7b. Relationship
112. 7c. Date of Birth
114. 7d. Gender

     1. Male
     2. Female
     3. Other
115. 7e. Race

     1. White
     2. Black or African American
     3. Asian
     4. American Indian or Alaska Native
     5. Pacific Islander
     6. Other
116. 7f. Ethnicity

     1. Hispanic
     2. Non-Hispanic
118. Person 8
120. 8a. Name
121. 8b. Relationship
122. 8c. Date of Birth
124. 8d. Gender

     1. Male
     2. Female
     3. Other
125. 8e. Race

     1. White
     2. Black or African American
     3. Asian
     4. American Indian or Alaska Native
     5. Pacific Islander
     6. Other
126. 8f. Ethnicity

     1. Hispanic
     2. Non-Hispanic

128. WARNING: Whoever, knowingly and willingly makes or uses a document or writing containing any false fictitious or fraudulent statement or entry may be subject to federal prosecution.

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129. 1. Receive an email copy of this form.
130. Email address

     This field is not part of the form submission.

131. Submit

* indicates a required field