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VII (I) Discussion Re: Recreation Scholarship Programs and Use of Freedom Park
Agenda 9-16-2003 Mayor ,�Gmta of Good Ll Commissic VI I S. Scott Vandergrift ,►,.!!"� ..,..,,, Danny Howell,District 1 L.': Scott Anderson,District 2 City Manager Rusty Johnson, District 3 Jim Gleason Nancy J. Parker,District 4 / STAFF REPORT The Honorable Mayor and City Commissioners Fr---T: Johnny Farmer, Parks and Recreation Director E: September 10, 2003 Before and After School Scholarship Program and Use of Freedom Park ISSUE As requested by the City Manager, attached please find information on the Before and After School Scholarship Program at the Parks and Recreation Department and a Field Use permit for Freedom Park. BACKGROUND/DISCUSSION N/A RECOMMENDATION N/A Only One Appicatlon Per Family City Of Ocoee Recreation Department 2002-2003 year Dear Parent/Guardian: If you now receive Food Stamps or Temporary Assistance for Needy Families(TANF)(formerly AFDC)for your child,your child could receive free tuition. If your total household income is the same or less than the amounts on the Income Chart below, your child could receive tree or reduced tuition. A foster child may receive free tuition regardless of your income. HOW TO APPLY: Complete the application form attached to this letter. list all school children in your 2003-2004 INCOME GUIDELINES household on one application. FOOD STAMPS OR TANF HOUSEHOLD: If you now Household Size Annually Monthly Weekly receive Food Stamps or TANF for the child you are applying for,that child is eligible for free tuition Yon 1 .16,613 1,385 320 will receive a notice of your child's eligibility. 2 22,422 1,869 432 If you do not want those benefits,you must notify Vignetti Recreation Department. 3 28,231 2,353 543 To apply,you only have to list the names of your children 4 34,040 2,837 655 and the Food Stamp or TANF case number for each child,print 5 39,849 3,321 767 your name,and sign the application 6 .45,658 3,805 879 7 51,467 4,289 990 FOSTER CHILD: In certain cases foster children are also eligible for these benefits. 8 57,276 4,773 1,102 If you have such children living with you and wish to apply for such tuition for them, please indicate their status on the application,or contact the Recreation Department For each if you have questions. additional family member,add +5,809 +485 +112 ALL OTHER HOUSEHOLDS: If you do not list a Food Stamp or TANF case number for the child you are applying for,then you must write the child's name,the names of all household members,the amount of income each person received last month and where it came from,the signature of an adult household member and that adult's social security number or the word"none"if the adult does not have a social security number. REPORTING CHANGES: If your child receives free or reduced tuition because of your income,you must fill out a new application. If your household size changes or your income increases by more than$50 per month or$600 per year. If your child receives tuition based on Food Stamp or TANF information,you must tell the department if you no longer receive Food Stamps or TANF for your child. You may then fID out another application giving income information. INCOME THAT MUST BE REPORTED EARNINGS FROM WORK PENSIONS/ WELFARE RETIREMENT/ CHILD SUPPORT/ OTHER INCOME SOCIAL SECURITY ALIMONY Wages/Salaries/Tips Pensions Public Assistance Disability Benefits Strike Benefits Supplemental Security Income Welfare Payments Cash Withdrawn from Savings Unemployment Compensation Retirement Income Alimony Payments Interest/Dividends Net Rental Net Royalties Annuities Worker's Compensation Veteran's Payments Child Support Payments Income from Estate/Trusts/ Investments Net Income from Self-Owned Regular Contributions from Business or Farm Social Security Persons Not Living In The Household Any Other Income CONFIDENTIALITY: City of Ocoee uses the information on the application to decide if your child should receive free or reduced tuition. Unless indicated otherwise on the application,the information on the free and reduced tuition application may be used by the Department in determining whether the child is eligible. REAPPLICATION: You may apply for free or reduced tuition any time during the year. If you are not eligible now but have a change,like decrease in household income,and increase in household size,become Unemployed or get Food Stamps or TANF for your child,you may complete a new application NO CHILD WILL BE DISCRIMINATED AGAINST BECAUSE OF RACE,SEX,COLOR,NATIONAL ORIGIN,and AGE, OR HANDICAP. IF YOU BELIEVE YOU HAVE BEEN DISCRIMINATED AGAINST,WRITE TO THE SECRETARY OF AGRICULTURE,WASHINGTON,D.C. 20250. We will let you know when your application is approved or denied. Sincerely, FAMILY APPLICATION FOR FREE AND REDUCED PRICE TUITION To apply for free and reduced price tuition,read the instructions and complete one application for all school children in your household. You must sign your name and fill in your social security number or your application will not be complete. We cannot approve an application.which is incomplete. Return one completed application to the Recreation Department in which your child or children are enrolled. Attach another sheet of paper if more space is needed. Check here if your child received free or red uced tuition during the 2001-2002 school year. PART 1 ALL HOUSEHOLDS COMPLETE THIS PART PART 2 Households getting Food Stamps Print name,ID number,school,and date of birth for all the or TANF(formerly AFDC)must list a current children in your household attending daycamp. If applying case number for each child. Complete this for foster children, complete a separate application part and PART 5. Do not complete PART for each child. 3 or 4. Name SCHOOL DATE OF Food Stamp Number TANF Number BIRTH PART 3-FOSTER CHILD: If this is a foster child,check this box List the Child's monthly personal income $ Write"0"if the child has no personal use income. COMPLETE THIS PART AND PART 5. PART 4-HOUSEHOLD MEMBERS AND MONTHLY INCOME: (1) Write the names of all persons in your household,whether they get income or not. Include yourself,the children you are applying for all other children,your spouse and any related or unrelated people in your in your household. Use another piece of paper if you need more space.(2)Write amount of monthly income each household member made last month before taxes o or anything else is taken out,listing it in the column that shows where it came from:earnings,welfare,pensions,other income. If the amount last month was more than usual,write the persons usual monthly income. Please refer to the INCOME THAT MUST BE REPORTED on reverse side of this application. (3) An adult household member must sign the application and give his/her social security number in Part 5. NAMES MONTHLY INCOME (x 2) (To figure monthly income:Weekly x4.33 Every 2 Weeks x2.15 Twice a month LIST THE NAMES OF EVERYONE Gross Monthly Earnings Monthly Monthly Job 2 or any IN YOUR HOUSEHOLD Earnings(Before Welfare,Child Pensions,SS Other month Deductions from main job) Support,Alimony Retirement ly Income $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Page 1 1 � • PART 5- ALL HOUSEHOLDS COMPLETE THIS PART(1)An adult household member must sign the application before it can be approved. (2) The application MUST have the social security number of the person who signs. (If you listed a food stamp or TANF number for each child or if you are applying for a foster child,a social security number is not neede<eded.) I certify that all the above information is true and correct and that all income is reported. I understand that this information is being given for reduced tuition;that City officials may verify the information on the application;and that deliberate misrepresentation of the information may subject disqualification of child from the program. 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Za O2 WOL or car - O • DEm2 ip fO E J . au �� Z ° c �� ).-i ...0 i I i Lf $� 32Ec �.Wyta AS $ aa 8. 2E ° i it y gl . 1islsu. - a. LQmC) BOWS « ii"▪ g p tEtg aa_ O 'i 4 .. aIS � 1iti- i2 25Elq .iVI 10 CO 1-CO 0) 2 L. �U F- , F1-F"H 1-.I�HH 1.... m. S � § =daad .:..- O. aaaCLWLett aa ElE LLoN cg gig Zl <2 # g Ee • eca;CIJCn Only One Application Per Family City Of Ocoee Recreation Department 2002-2003 year Dear Parent/Guardian: If you now receive Food Stamps or Temporary Assistance for Needy Families(TANF)(formerly AFDC)for your child,your . child could receive free tuition. If your total household income is the same or less than the amounts on the Income Chart below, your child could receive free or reduced tuition. A foster child may receive free tuition regardless of your income. HOW TO APPLY: Complete the application form attached to this letter. List all school children in your 2002-2003 INCOME GUIDELINES household on one anolication. FOOD STAMPS OR TANF HOUSEHOLD: If you now Household Size Annually Monthly Weekly receive Food Stamps or TANF for the child you are applying for,that child Is eligible for free tuition. You 1 .15,892 1,325 306 will receive a notice of your child's eligibility. 2 21,479 1,790 414 If you do not want those benefits,you must notify Vignetti Recreation Department. 3 27,066 2,256 521 To apply,you only have to list the names of your children 4 32653 2722 628 and the Food Stamp or TANF case number for each child,print 5 38,240 3,187 736 your name,and sign the application. 6 .43,827 3,653 843 7 49,414 4118 .951 FOSTER CHILD: In certain cases foster children are also eligible for these benefits. 8 55,001 4,584 .1,058 If you have such children living with you and wish to apply for such tuition for them, please indicate their status on the application,or contact the Recreation Department For each if you have questions. additional funny member,add +5,587 +466 +108 ALL OTHER HOUSEHOLDS: If you do not list a Food Stamp or TANF case number for the child you are applying for,then you must write the child's name,the names of all household members,the amount of income each person received last month and where it came from,the signature of an adult household member and that adult's social security number or the word"none"if the adult does not have a social security number. REPORTING CHANGES: If your child receives free or reduced tuition because of your income,you must fill out a new application. If your household size changes or your income increases by more than$50 per month or$600 per year. If your child receives tuition based on Food Stamp or TANF information,you must tell the department if you no longer receive Food Stamps or TANF for your child. You may then fill out another application giving income information. INCOME THAT MUST BE REPORTED EARNINGS FROM WORK PENSIONS/ WELFARE RETIREMENT/ CHILD SUPPORT/ OTHER INCOME SOCIAL SECURITY ALIMONY Wages/Salaries/Tips Pensions Public Assistance Disability Benefits Strike Benefits Supplemental Security Income Welfare Payments Cash Withdrawn from Savings Unemployment Compensation Retirement Income Alimony Payments Interest/Dividends Net Rental Net Royalties Annuities Worker's Compensation Veteran's Payments Child Support Payments Income from Estate/Trusts/ Investments Net Income from Self-Owned Business or Farm Social Security Regular Contributions from Persons Not Living In The Household Any Other Income CONFIDENTIALITY: City of Ocoee uses the information on the application to decide if your child should receive free or reduced tuition. Unless indicated otherwise on the application,the information on the free and reduced tuition application may be used by the Department in determining whether the child is eligible. REAPPLIc.ATION: You may apply for free or reduced tuition any time during the year. If you are not eligible now but have a change,like decrease in household income,and increase in household size,become Unemployed or get Food Stamps or TANF for your child,you may complete a new application. • NO CHILD WILL BE DISCRIMINATED AGAINST BECAUSE OF RACE,SEX,COLOR,NATIONAL ORIGIN,and AGE, OR HANDICAP. IF YOU BELIEVE YOU HAVE BEEN DISCRIMINATED AGAINST,WRITE TO THE SECRETARY OF - AGRICULTURE,WASHINGTON,D.C. 20250. We will let you know when your application is approved or denied. 1 1 L 11(Sincerely, (1/4d/1 /1% ;, FAMILY APPLICATION FOR FREE AND REDUCED PRICE TUITION To apply for free and reduced price tuition,read the instructions and complete one application for all school children in your household. You must sign your name and fill in your social security number or your application will not be complete. We cannot approve an application.which is incomplete. Return one completed application to the Recreation Department in which your child or children are enrolled. Attach another sheet of paper if more space is needed. Check here if your child received free or red uced tuition during the 2002-2003 school year. ti� PART 1 ALL HOUSEHOLDS COMPLETE THIS PART PART 2 Households getting Food Stamps Print name,ID number,school,and date of birth for all the or TANF(formerly AFDC)must list a current children in your household attending daycamp. If applying case number for each child. Complete this for foster children, complete a separate application part and PART 5. Do not complete PART for each child. 3 or 4. 1 Name SCHOOL DATE OF Food Stamp Number TANF Number BIRTH 111L, dat2_'1 . .3 SI? ?Cl'7' t- w �.1 �. PART 3-FOSTER CHILD: If this is a foster child,check this box List the Child's monthly personal income $ Write"0"if the child has no personal use income. COMPLETE THIS PART AND PART 5. PART 4-HOUSEHOLD MEMBERS AND MONTHLY INCOME: (1) Write the names of all persons in your household,whether they get income or not. Include yourself,the children you are applying for all other children,your spouse and any related or unrelated people in your in your household. Use another piece of paper if you need more space.(2)Write amount of monthly income each household member made last month before taxes o or anything else is taken out,listing it in the column that shows where it came from:earnings,welfare,pensions,other income. If the amount last month was more than usual,write the persons usual monthly income. Please refer to the JNCOME THAT MUST BE REPORTED on reverse side of this application. (3) An adult household member must sign the application and give his/her social security number in Part 5. NAMES MONTHLY INCOME (x 2) (To figure monthly income:Weeldy x4.33 Every 2 Weeks x2.15 Twice a month LIST THE NAMES OF EVERYONE Gross Monthly Earnings Monthly Monthly Job 2 or any IN YOUR HOUSEHOLD Earnings(Before Welfare,Child Pensions,SS Other month Deductions from main job) Support,Alimony/!9j Z3 ac Retirement ly Income ct:tL $/6CC' $ticiCVC,'/ tan.�'% $ $3CC.CO • ,);: 4,Jcl;. , . $ fc-��— '- `Ni, -(\i\ f4t%r\L' ck4C; $ if . • $ —C $ -f=- $ $ $ $ $ , $ $ $ $ _$ Page 1 • PART 5- ALL HOUSEHOLDS COMPLETE THIS PART(1)An adult household member must sign the application before it can be approved. (2) The application MUST have the social security number of the person who signs. (If you listed a food stamp or TANF number for each child or if you are applying for a foster child,a social security number is not needec eded.) I certify that all the above information is true and correct and that all income is reported. I understand that this information is being given for reduced tuition;that City officials may verify the information on the application;and that deliberate misrepresentation of the information ma subject disqualification of child from the program. Check here if additional sheets attached._ ez,2 Date 7(1'IL. Social Security Number $1'—2-4)•(4 77 Signature of Adult Household Member (Write NONE if you don't have a SS number) k7 Ceti Printed Name /10-4:/?.174" L ?leaf Home Phone No.c .347 Work Phone No. 70 1 .297-44# Address �'��C'� ' City2ip (Peee/ Page 2 r- • _- • _ • 0 , :, NkRATN E R RATNER COMPANIES, L.C. cHE« NO: A141827 4518 NARTLANO ROAD CHECK DATE: 07/08/09 COMPANIES FALLS CHURCH, VA 22043 PE71100 ENDING: 06/28/03 PAY FREQUENCY: • .EAR.THERESA BSN: 694-20-6871 NUMBER: 0224784420 TAX STATUS: SINGLE 4 CENTRAL ST EXEMPTIONS: FED: 00 STATE: 03 STATE CODE: PRI: FL SEC: FL LOCAL CODE: LOCI: LOC2: LOCS: TAX ADJ:. FED: STATE: . E01/UC ALT: LOCAL ALT: AEE FL 34761 BASE RATE: IMPORTANT MESSAGE HOURS AND EARNINGS TAXES AND DEDUCTIONS SPECIAL INFORMATION ' CURRENT Y-T-D CURRENT Y-T-D ESCRIPTJON HOURS/UNITS EARNINGS HOURS/UNITS EARNINGS DESCRIPTION_ AMOUNT AMOUNT . guisr 83.50 303.70 484.25 2799.59 SO SEC TAX 24.41 175.97 PTO BALANCE .00 MEDICARE TAX 5.71 41.15 RESERVE SAL .00 , FED INC TAX 30.21 224.84 Clients Svd 58.00 . . TOTAL TAXES 80.33 441.98 ATTER-LAX DEDUCTIONS •TAL E 83.50 303.70 484.25 2799.59 PRE-TAX ITEMS • • • CURRENT NET PAY DISTRIBUTION C8027792780 333.37 CHECK AMOUNT .00 TAL PRE-TAX TAL 83.50 303.70 484.25 2799.59 TOTAL PER DED GROSS PRE-TAX TAXABLE AAGES LESS TAXES LESS DEDS E0 NEI PAY WENT 393.70 , .00 • 393.70 90.33 .00 333.37 - T-0 2838.18 .00 2838.18 441.98 .Q0 2398.22 TOTAL CURRENT MET PAY 333.37 Statement Of Earnings Detach at perforation below and keep for your records. A Payroll Service By Ceridian • egRAT H E R RATNER COMPANIES. L.C. 2815 HARTLAND ROAD COMPANIES FALLS CHURCH, VA 22043 ,, .,,, . . DATE 07-08-03 . A141827 . . JR ENTIRE NET PAY HAS BEEN DEPOSITED IN YOUR BANK ACCOUNT(S) PLEASE REVIEW "CURRENT NET PAY DISTRIBUTION" SECTION OF YOUR STATEMENT OF EARNINGS FOR DETAILS. I ''' BREAR,THERESA NOT NEGOTIABLE - 904 CENTRAL ST .., 4.444-` OCOEE FL 34761 - .fi1i? ' . . . THE FACE OF THIS DOCUMENT HAS A MULTI-COLORED BACKGROUND ON WHITE PAPER AS WEl L AS NUMEROUS OTHER SECURITY FEATURES • - • • . . • • RATNER COMPANIES. L.C. , RATNERa.« ND: A131590 2818 HARTLAND ROAD CHECK DATE: 09/24/03 COMPANIES FALLS CHURCH. VA 2204$ PER100 ENDING: 08/31/08 PAY FREQUENCY: • IREM.THERESA BSN: 894-20-8871 NUMBER: 0224784430 • TAX STATUS: SINGLE )04 CENTRAL ST EXEMPTIONS: FED: 00 STATE: 03 STATS CODE: PRI: FL SIC: FL LOCAL ODDS: LOCI: LOC2: Lop: TAX ADJ: FED: STATE: SDI/UC ALT: LOCAL ALT:. OCOEE FL 34781 - SASS MTS: IMPORTANT MESSAGE HOURS AND EARNINGS TAXES AND DEDUCTIONS SPECIAL INFORMATION • CURRENT • Y-T-D CURRENT Y-T-D DESCRIPTION FOURS/UNITS EARNINGS FLOURS/UNITS EARNINGS DESCRIPTION AMOUNT AMOUNT • *tail 9.88 38.59 SO SEC TAX .61 122.44 PTO BALANCE .00 MEDICARE TAX .15 28.64 RESERVE SAL .00 FED INC TAX 153.03 TOTAL TAXES .76 304.11 AFTER-TAX DEDUCTIONS • AL E 9.86 38.59 PRE:-TAX ITEMS CURRENT NET PAY DISTRIBUTION 8027792780 9.10 CHECK AMOUNT .00 • , 3TAL PRE-TAX • AL 9.86 38.59 TOTAL PER DED GROSS PRE-TAX TAXABLE AAGES LESS TAXES LESS DEDS EO NET PAY JRRENT 9.86 .00 9.86 , .76 .00 9.10 -T-0 1974.83 .00 1974.83 304.11 , .00 1670.72 TOTAL CURRENT NET PAY 9.10 • Statement Of Earnings Detach at perforation below and keep for your records. A Payroll Service By Ceridian . " 1. rrµl° RATNER COMPANIES L.C. RAIN E FV 2818 HARTLAND ROAD C O M PA,N y. >' �'ge l,l'''41iii"�'^'II' FALLS CHURCH, VA 22043 • ;,,;*. T,.:,Ix: THC-1 � " DATE 06-24-03 A131590 - ;'a' • UR ENTIRE NET PAY 'i.; DEPOSITED IN YOUR BANK ACCOUNTS PLEASE REVIEW E "CURRENT NET P Y.` ;440 • . ( ) r,.A S RI,BUTION ,;:SECTION OF YOUR STATEMENT OF EARNINGS FOR DETAILS. • ' BREAR.THERESA • NOT NEGOTIABLE 3 ,9 CENTRAL ST •F L 34761 • THE FACE OF THIS DOCUMENT HAS A MULTICOLORED BACKGROUND ON WHITE PAPER AS WELL AS NUMEROUS OTHER SECURITY FEATURES . • • • • . < ....... < • • • • • •b ). . . . . o ).- 1 z o Lo cq N ,-i 1 • * cc r- < i r-4 • P . CL) Z < D - Ili .-. uj C.) 0 0 a) r 0- `-' >- ON 6 a I- U.I (.) el ev) * .11.11.101. in Lo co cc R z L.r)r-c•I TS 2 I- 8 • • • r•-) 0 i UJ 2 Ln cr,N ill 0 rO _ o rl .o - I- ItOZT) (.)..s•• fO W < UJ r•••• 0 (CI o N- •cco 44 W ii-i r.1-1 r2.4 X..i Cf) Z 2 0 Jg o cm * a m r:4 c tO 5 ta > w 9 • • OT. oN 0 rt 0 0 Ln xi ..1 17 r-di rn •,-1 0 LU CtI I-: CC In Cr T-1 .... < r• < 0 CO 0 --- W < d LAJ 01 2 L) 0 1.".." 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D W O H r,. ey:: - G v �1 , . . . , pc- PP J . . . ;: Only One Application Per Family City Of Ocoee Recreation Department 2002-2003 year Dear Parent/Guardian: If you now receive Food Stamps or Temporary Assistance for Needy Families(TANF)(formerly AFDC)for your child,your child could receive free tuition. If your total household income is the same or less than the amounts on the Income Chart below, your child could receive free or reduced tuition. A foster child may receive free tuition regardless of your income. HOW TO APPLY: Complete the application form attached to this letter. List all school children in your 2002-2003 INCOME GUIDELINES household on one armlleation. FOOD STAMPS OR TANF HOUSEHOLD: If you now Household Size Annually Monthly Weekly receive Food Stamps or TANF for the child you are applying for,that child is eligible for free tuition. You 1 15,892 1,325 306 will receive a notice of your child's eligibility. 2 21,479 1,790 .414 If you do not want those benefits,you must notify Vignetti Recreation Department. 3 27,066 2 256 .521 To apply,you only have to list the names of your children 4 .32,653 2,722 628 and the Food Stamp or TANF case number for each child,print 5 .38,240 3,187 736 your name,and sign the application. 6 .43,827 3,653 843 7 49,414 4,118 951 FOSTER CHILD: In certain cases foster children are also eligible for these benefits. 8 55,001 4,584 1,058 If you have such children living with you and wish to apply for such tuition for them, please indicate their status on the application,or contact the Recreation Department For each if you have questions. additional family member,add +5,587 +466 +108 ALL OTHER HOUSEHOLDS: If you do not list a Food Stamp or TANF case number for the child you are applying for,then you must write the child's name,the names of all household members,the amount of income each person received last • month and where it came from,the signature of an adult household member and that adult's social security number or the word"none"if the adult does not have a social security number. REPORTING CHANGES: If your child receives free or reduced tuition because of your income,you must fill out a new application. If your household size changes or your income increases by more than S50 per month or$600 per year. If your child receives tuition based on Food Stamp or TANF information,you must tell the department if you no longer receive Food Stamps or TANF for your child. You may then fill out another application giving income information. INCOME THAT MUST BE REPORTED I EARNINGS FROM WORK PENSIONS/ WELFARE RETIREMENT/ CHILD SUPPORT/ OTHER INCOME SOCIAL SECURITY ALIMONY Wages/Salaries/Tips Pensions Public Assistance Disability Benefits Strike Benefits Supplemental Security Income Welfare Payments Cash Withdrawn from Savings Unemployment Compensation Retirement Income Alimony Payments Interest/Dividends Net Rental Net Royalties Annuities Worker's Compensation Veteran's Payments Child Support Payments Income from Estate/Trusts/ Investments Net Income from Self-Owned Business or Farm Social Security Regular Contributions from Persons Not Living In The Household Any Other Income CONFIDENTIALITY: City of Ocoee uses the information on the application to decide if your child should receive free or reduced tuition. Unless indicated otherwise on the application,the information on the free and reduced tuition application may be used by the Department in determining whether the child is eligible. REAPPLICATION: You may apply for free or reduced tuition any time during the year. If you are not eligible now but have a change,like decrease in household income,and increase in household size,become Unemployed or get Food Stamps or TANF for your child,you may complete a new application. NO CHILD WILL BE DISCRIMINATED AGAINST BECAUSE OF RACE,SEX,COLOR,NATIONAL ORIGIN,and AGE, OR HANDICAP. IF YOU BELIEVE YOU HAVE BEEN DISCRIMINATED AGAINST,WRITE TO THE SECRETARY OF AGRICULTURE,WASHINGTON,D.C. 20250. We will let you know when your application is approved or denied. Sincerely, -.\\6 / L \\ i 1 FAMILY APPLICATION FOR FREE AND REDUCED PRICE TUITION To apply for free and reduced price tuition,read the instructions and complete one application for all school children in your household. You must sign your name and fill in your social security number or your application will not be complete. We cannot approve an application.which is incomplete. Return one completed application to the Recreation Department in which your child or children are enrolled. Attach another sheet of paper if more space is needed. Check here if your child received free or red uced tuition during the 2001-2002 school year. PART 1 ALL HOUSEHOLDS COMPLETE THIS PART PART 2 Households getting Food Stamps Print name,ID number,school,and date of birth for all the or TANF(formerly AFDC)must list a current children in your household attending daycamp. If applying case number for each child. Complete this for foster children, complete a separate application part and PART 5. Do not complete PART for each child. 3 or 4. I Name SCHOOL DATE OF Food Stamp Number TANF Number BIRTH c 1 S-1'.?A) �� � OC,Oe 1].I i1ct3 P ���sh S�p� ^��, (off PART 3-FOSTER CHILD: If this is a foster child,check this box List the Child's monthly personal income $ Write"0"if the child has no personal use income. COMPLETE THIS PART AND PART 5. PART 4 HOUSEHOLD MEMBERS AND MONTHLY INCOME: (1) Write the names of all persons in your household,whether they get income or not. Include yourself,the children you are applying for all other children,your spouse and any related or unrelated people in your in your household. Use another piece of paper if you need more space.(2)Write amount of monthly income each household member made last month before taxes o or anything else is taken out,listing it in the column that shows where it came from:earnings,welfare,pensions,other income. If the amount last month was more than usual,write the persons usual monthly income. Please refer to the INCOME THAT MUST BE REPORTED on reverse side of this application. (3) An adult household member must sign the application and give his/her social security number in Part 5. NAMES MONTHLY INCOME (x 2) (To figure monthly income:Weekly x4.33 Every 2 Weeks)2.15 Twice a month LIST THE NAMES OF EVERYONE Gross Monthly Earnings Monthly Monthly Job 2 or any IN YOUR HOUSEHOLD Earnings(Before Welfare,Child Pensions,SS Other month Deductions from main job) Support,Alimony Retirement ly Income S $ %!-C1). O $ $ $ e1 $ $ $ $ —SC S\-\•._ $ $ $ $ �:.,\� i•,,�vJ $ $ $ $ $ $ $ $ $ _$ $ $ Page 1 • j.• p . . r PART 5- ALL HOUSEHOLDS COMPLETE THIS PART(1)An adult household member must sign the application before it can be approved. (2) The application MUST have the social security number of the person who signs. (If you listed a food stamp or TANF number for each child or if you are applying for a foster child,a social security number is not needec eded.) I certify that all the above information is true and correct and that all income is reported. I understand that this information is being given for reduced tuition;that City officials may verify the information on the application;and that deliberate misrepresentation of the information may •ject disqualification child from the program. Check here if additional sheets attached. , •� Date,f�(� Social Security Number Qui—S3 --CSS Signature of Adult H•r,•Id Member TT (Write NONE if you don't have a SS number) Printed Nam &L1,-«`--C `l ome Phone Nog t" Work Phone No.'70 877—CO Address ' `t e.( 'e_ City/zip (TX C ce_ r 17 o • . j.j Page 2 • • _ - - CHICK NUMBER: 1111164 V MPLOYEE NAME: Laura A. Sapp iSN: 263-83-O0S1 FED EXEMPTIONS: 00 'CENTER: 0342 - OCOEE MIDDLE SCHOOL CHECK Di:TH:, 04/30/2003 FED STATUS: Merril PAY PERIOD: 04/08/2003 Thru 04/20/2003 PERSONNEL NO: NEL gUgA40213CLE7 - 188 Class/7 hrs PR AREA: 84 - 188 Day C1ass.10mth 1 - DETAIL OF MISCELLANEOUS DEDUCTIONS SUMMARY OF EARNINGS AND DEDUCTIONS CALENDAR YTD I - • THIS CHECK CALENDAR YTD THIS CHECK 21.58 317.60 OCAS 21.58 .OTALaI COMES 317.60 3,473.91 TOTS bTAL INCOME ESS: 19.70 197.55 ?ICA ledicare 4.60 97.55 121.95 iithholding Tax 6.9521.58• tisc.Deduct(See Detail) 3,082.46 tet Pay 286.35 t - !-- LEAVE INFORMATION IN HOURS SICK LEAVE USED 18.50 SICK BANK N . SICK LEAVE BALANCE 0.00 PERSONAL LEAVE USED 0.00 PERSONAL LEAVE BALANCE '35.00 YOU MUST HAVE A SICK ANNUAL LEAVE USED 0.00 LEAVE BALANCE IN (ANNUAL LEAVE BALANCE 0.40 ORDER TO TAKE 'SICK BANK CONTRIBUTION 0.00 PERSONAL LEAVE WITH PAY EMPLOYER CONTRIBUTION • EARNINGS INFORMATION OCPS Paid Life Insurance 1.00 6.00 ANNUAL SALARY 0.00 Regular Retirement Plan 18.29 183.51 • !CONTRACT SALARY 0.00 TOTAL 19.29 189.51 'PERIOD PAY 430.29 ! 'DAILY PAY 47.81 HOURLY PAY 6.83 !REGULAR PAY HOURS 46.50 STRAIGHT OVERTIME HOURS 0.00 !TIME AND 1/2 HOURS 0.00 DOUBLE OVERTIME HOURS 0.00 (DOCKED HOURS 16.50 I • • I • • _ - - CHICK NUMBER: 1111164 V MPLOYEE NAME: Laura A. Sapp iSN: 263-83-O0S1 FED EXEMPTIONS: 00 'CENTER: 0342 - OCOEE MIDDLE SCHOOL CHECK Di:TH:, 04/30/2003 FED STATUS: Merril PAY PERIOD: 04/08/2003 Thru 04/20/2003 PERSONNEL NO: NEL gUgA40213CLE7 - 188 Class/7 hrs PR AREA: 84 - 188 Day C1ass.10mth 1 - DETAIL OF MISCELLANEOUS DEDUCTIONS SUMMARY OF EARNINGS AND DEDUCTIONS CALENDAR YTD I - • THIS CHECK CALENDAR YTD THIS CHECK 21.58 317.60 OCAS 21.58 .OTALaI COMES 317.60 3,473.91 TOTS bTAL INCOME ESS: 19.70 197.55 ?ICA ledicare 4.60 97.55 121.95 iithholding Tax 6.9521.58• tisc.Deduct(See Detail) 3,082.46 tet Pay 286.35 t - !-- LEAVE INFORMATION IN HOURS SICK LEAVE USED 18.50 SICK BANK N . SICK LEAVE BALANCE 0.00 PERSONAL LEAVE USED 0.00 PERSONAL LEAVE BALANCE '35.00 YOU MUST HAVE A SICK ANNUAL LEAVE USED 0.00 LEAVE BALANCE IN (ANNUAL LEAVE BALANCE 0.40 ORDER TO TAKE 'SICK BANK CONTRIBUTION 0.00 PERSONAL LEAVE WITH PAY EMPLOYER CONTRIBUTION • EARNINGS INFORMATION OCPS Paid Life Insurance 1.00 6.00 ANNUAL SALARY 0.00 Regular Retirement Plan 18.29 183.51 • !CONTRACT SALARY 0.00 TOTAL 19.29 189.51 'PERIOD PAY 430.29 ! 'DAILY PAY 47.81 HOURLY PAY 6.83 !REGULAR PAY HOURS 46.50 STRAIGHT OVERTIME HOURS 0.00 !TIME AND 1/2 HOURS 0.00 DOUBLE OVERTIME HOURS 0.00 (DOCKED HOURS 16.50 I • • I 4 • ' LEAVE INFORMATION IN HOURS . •- • • • • • SICK LEAVE USED . 0.00 .'SICK BANK .. N' •. . - SICK LEAVE BALANCE 0:00 • ' ' • • . • PER6ONAL LEAVE USED • 0.00 PERSONAL LEAVE BALANCE 35.00 YOU MUST HAVE A SICK . . •• . • ANNUAL LEAVE USED • 0.00 :LEAVE BALANCE IN . . " •- ANNUAL LEAVE BALANCE 0.00 ORDER TO TAKE . . , • SICK BANK CONTRIBUTION . G.00 PERSONAL LEAVE WITH .• . . . • . . . PAY , EARNINGS INFORMATION . EMPLOYER CONTRIBUTION ' ANNUAL SALARY ' 0.00 OCPS Paid Life Insurance . 1.00 ' • 7.00 . CONTRACT SALARY 0.00 ' Regular Retirement Plan -..24.78 • . 208.29- . ' PERIOD PAY 430.29 . ' I TOTAL ' 25.78 . ' 215.29 DAILY PAY 47.81 I . • HOURLY PAY 6.83 ' REGULAR PAY HOURS • 63.00 • : :. STRAIGHT OVERTIME HOURS 0.00 ITIME AND .1/2 HOURS 0.00. - . ' DOUBLE OVERTIME HOURS . 0.00 1 . DOCKED HOURS 0.00 ( . . ..)• VrV4111VC•th+V V1tl 1 I 11--vulg.'', J%+fIV VLJ ••••Y•3' VI ICJ I MIIICLIM J I fCC I Vfl1.Mlel/IJ f L JLuI,1 .. -- CHECK NUMBER : 1165594 • EMPLOYEE NAME: Laura A. Sapp SSN: 263-83-0051 FED EXEMPTIONS: 00 CENTER: 0342 - OCOEE MIDDLE SCHOOL CHECK DATE: 05/14/2003 FED STATUS: Married PAY PERICD: 04/21/2003 Thru 05/04/2003 PERSONNEL NO: 40213 PR AREA: 84 - 188 Day Class.l0mth PERSONNEL SUBAREA: CLE7 - 18i Class/7 hrs SUMMARY OF EARNINGS AND DEDUCTIONS DETAIL OF MISCELLANEOUS DEDUCTIONS • THIS CHECK CALENDAR YTD THIS CHECK CALENDAR YTD Regular Wages 430.29 OCAS 21.58 TOTAL :NCOME 430.29 3,904.20 TOTAL 21.58 LESS: FICA 26.67 224.22 Medicare 6.24 56.61 Withholding Tax 18.22 140.17 Misc.Deducc(See Detail) 21.58 Net Pay 379.16 3,461.62 1 I ' i FAMILY APPLICATION FOR FREE AND REDUCED PRICE TUITION To apply for free and reduced price tuition,read the instructions and complete one application for all school children in your household. You must sign your name and fill In your social security number or your application will not be complete. We cannot aoorove an aoplication.which is incomplete. Return one completed application to the Recreation Department in which your child or children are enrolled. Attach another sheet of paper if more space is needed. Check here if your child received free or red uced tuition during the 2002-2003 school year. PART 1 ALL HOUSEHOLDS COMPLETE THIS PART PART 2 Households getting Food Stamps • Print name,ID number,school,and date of birth for all the or TANF(formerly AFDC)must list a current children in your household attending daycamp. If applying case number for each child. Complete this for foster children, complete a separate application part and PART 5. Do not complete PART for each child. 3 or 4. Name SCHOOL DATE OF Food Stamp Number TANF Number BIRTH So ea. ,/ 1� �/ �r:n�ltJf.� f-f=93 yr ' • les -P1 Fla tjan tag.e. 5=d�f5 PART 3-FOSTER CHILD: If this is a foster child,check this box List the Child's monthly personal income $ Write"0"if the child has no personal use income. COMPLETE THIS PART AND PART 5. PART 4-HOUSEHOLD MEMBERS AND MONTHLY INCOME: (1) Write the names of all persons in your household,whether they get income or not. Include yourself,the children you are applying for all other children,your spouse and any related or unrelated people in your in your household. Use another piece of paper if you need more space.(2)Write amount of monthly income each household member made last month before taxes o or anything else is taken out,listing it in the column that shows where it came from:earnings,welfare,pensions,other income. If the amount last month was more than usual,write the persons usual monthly income. Please refer to the INCOME THAT MUST BE REPORTED on reverse side of this application. (3) An adult household member must sign the application and give his/her social security number in Part 5. NAMES MONTHLY INCOME (x 2) (To figure monthly income:Weekly x4.33 Every 2 Weeks x2.15 Twice a month LIST THE NAMES OF EVERYONE Gross Monthly Earnings Monthly Monthly Job 2 or any IN YOUR HOUSE);iOLD Earnings(Before Welfare,Child Pensions,SS Other month Deductions from main job) Support,Alimony Retirement ly Income 12,6104..1 M, 1—'t4r,: �n $ 855, co $ $ $ `� nn C � v� $ / .Som.-G2> $ • $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $$ $ $ Page 1 I PART 5- ALL HOUSEHOLDS COMPLETE THIS PART(1)An adult household member must sign the application before it can be approved. (2) The application MUST have the social security number of the person who signs. (If you listed a food stamp or TANF number for each child or if you are applying for a foster child,a social security number is not needec eded.) I certify that all the above information is true and correct and that all income is reported. I understand that this information is being given for reduced tuition;that City officials may verify the information on the application;and that deliberate misrepresentation of the information may subject disqualification o child from the program. Check here if additional sheets attached. K Date?�4.O 3 Social Security Number 3$6- 907-d%y 3 Cl igncature o Adult FIouseh ember (Write NONE if you don't have a SS number) D r Sca,inec 7/ bag 6 Printed Name n4Ck//1(fin: e& Home Phone No.96I 7-6 Work Phone No. 5/0 7 CC?7-0 7 / Address ad 3 r � ZC�1'.e C:ec te. City2ip 4C OL e`c/-3 '76/ Page 2 . . . • . , . . : • . — ______— -- ,(\ .,* „ 1 0 c•r.- el ei v., cci sat c..) Ir. i0 •lra ..1 / 71 si-as ----- A s i•-.1 rs• i cv c0 01 0 1 Z tu '-',1.4 Lu co a re co g 4: ,.,k m a • .. z ›, ; .-'4.47. '.'t. a. =‘,< • u. 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P fA e N teA W • - - • • 5 1-,fiafr*"'• . . • •- •• , • • r••. • .'.• . •••••• 411'.- 5•, • ••••,- ;••• - • • „ „. , - . • . 5 r` • .4 t4 ' - ,••• • • 4 :#^ • • •• " ••••' ^, • ' (1ZItt. .t, S,S ••,;-."1"''A • - • • -f• ;•-•.5;-••4?'••-•4" . • • _ 4••••••• • •74. - • • • 114. .- . . ss. • • • ,,, ,,,,, PC. • • • • - —77 • S . +500 • Llii C () ,,-)0 • 66L66 n + 0 6 • + _ • * nO • n • • 'J • • +;,r;Q • riC /.00 i • '• • C' • s • • • • • 411 • • • CairMer.-- Ocoee City Commission Regular Meeting November 16, 1999 City Clerk and further authorize all necessary actions in order to proceed to acquire the properties by quick-take proceeding. Motion carried 5-0. Ms. Doty said she will be filing condemnatiancy within the next seven days and the order of taking hearing will be after the first of the year. She said it was possible they may be able to acquire the properties without having to condemn them, and, if so, she will dismiss the property owner from the suit and bring a negotiated purchase to Commission. RESOLUTION No. 99-20, RE: CREDIT CARDS City Attorney Rosenthal read Resolution No. 99-20 by title only. Finance Director Horton presented the staff report for the proposed resolution to enter into an agreement with SunTrust for the issuance of the VISA Corporate Card to the Mayor, City Commissioners, and City Staff. In response to a question from the Mayor, she explained that the City was changing because American Express requires that the individual to whom the card is issued is personally liable and currently that has been the City Manager, and that the annual membership fee would be less with SunTrust. Commissioner Anderson suggested that changes to the account should require the Mayor and one other individual rather than any two of the three individuals listed. Mr. Shapiro said this was the usual procedure and Mr. Rosenthal explained this refers more to administrative paper work that may come to the City during the course of the administration of the card, and would typically be done by the City Manager and Finance Director. As had been recommended by staff, Mayor Vandergrift, seconded by Commissioner Howell, moved to approve Resolution No. 99-20 and authorize the Mayor, City Clerk and Staff to execute all documents necessary to effect the transaction. Motion carried 4-1, with Commissioner Anderson voting "No." RECESS - 9:07 p.m. - 9:30 p.m. • DISCUSSION: BEFORE/AFTER SCHOOL PROGRAM- PAYMENT/SCHOLARSHIP PROGRAMS Recreation Director Nordquist presented the staff report. Mayor Vandergrift, seconded by Commissioner Howell, moved to approve the program as • recommended by staff. The program was discussed at length. Commissioner Johnson, seconded by Commissioner Anderson, moved to amend the motion to not forgive amount in arrears, except for those people who would qualify under the new guidelines for scholarships. Motion carried 4-1, with Mayor Vandergrift voting "No." Ocoee City Commission Regular Meeting November 16, 1999 Commissioner Anderson, seconded by Commissioner Parker, moved to amend the motion to allow those individuals in arrears who do not meet the requirements of the scholarship to have one year from the effective date of starting the program to pay the amount in arrears. Motion carried 3-2 with Mayor Vandergrift and Commissioner Johnson voting "No." The vote on the motion as amended carried 4-1, with Mayor Vandergrift voting"No." AWARD OF SERVICES AUTHORIZATION 99-007 FOR ENGINEERING SERVICES TO HARTMAN & ASSOCIATES, INC. FOR THE A.D. MIMS AND WURST ROAD AREA IMPROVEMENT PROJECT Assistant City Engineer Wheeler presented the staff report. Commissioner Johnson commented about the need for sidewalks from the Beech Center, down both sides of Clarke Road and all the way to Prairie Lake. Mr. Shapiro said staff would need to report back with information about costs/funding for the sidewalks. Mayor Vandergrift questioned including resurfacing of the ten residential streets along with the A.D. Mims Road/Wurst Road project as he felt that should not require engineering services. He was concerned that widening of Wurst might encourage speeding on the road. Mr. Wheeler said that Wurst was scheduled for widening to a uniform width for safety reasons and that there are no plans to change the speed limit. He said the resurfacing of the residential streets had been included in the maintenance overlay of the roads which Public Works was going to do but would be included in this project and paid for under the transportation bond issue. He said the engineers will be delineating the areas where the work is to be done, but the majority of the design work will be for Wurst Road. Mr. Shapiro explained the need to remedy the "sickness" of the roads in the area and said the project will make the "streetscape" look better for the people living along it. The majority of the cost is for the design of Wurst Road and the ribbon curb and the only money they are being paid on the rest of it is the preparation of the bid documents so the projects may be begun. Mayor Vandergrift said he did not want to wait on the resurfacing of the roads until engineering was done on Wurst and A.D. Mims Roads. Mr. Wheeler said the project should be out to bid in 90 days. As had been recommended by staff, Commissioner Johnson, seconded by Commissioner • Anderson moved to authorize the Mayor and City Clerk to execute Services Authorization No. 99-007 with Hartman & Associates, Inc. in the not-to-exceed amount of$47,860.00, and further, that the listed resurfacing projects provided by the Public Works Department be included with the A.D. Mims Road Improvements Project. .Motion carried 4-1, with Mayor Vandergrift voting "No." 8 • Agenda 11-16-99 Item VII D "CENTER OF GOOD LIVING-PRIDE OF WEST ORANGE" MAYOR•COMMISSIONER Ocoee S. SCOTT VANDERGRIFT 0 crs CITY OF OCOEE COMMISSIONERS 410 a 150 N. LAKESHORE DRIVE DANNY HOWELL SCOTT ANDERSON OCOEE,FLORIDA 34761-2258 RUSTY JOHNSON (407)654-1608 NANCY J,PARKER eip Gf GOOO`` CITY MANAGER ELLIS SHAPIRO STAFF REPORT To: Honorable Mayor and Board of Commissioners From: Bnice Nordquist, CLP, Recreation Director Date: November 10, 1999 RE: Before/After School Program 1. Payment Policy 2. Scholarship Program Issue: To discuss installing a"Payment Policy" and/or "Scholarship Program" in the before/after school program. 1. Payment Policy: Background: There is a collection problem that exists concerning the payment policy of the before/after school program. Parents are routinely asked verbally and through written letters to make payments but continue to neglect our pleas. A written policy in place would allow the Recreation staff more leverage for collection because it would put pressure on parents to pay fees or their children will not be allowed to participate in the program. The program cost is only $15.00 per week for the after school program and $10.00 per week for the before school program. We feel this price is quite reasonable in light of the price of other before/after school programs available in and around the City. Recommendation: Attached please find a proposed written payment policy, which states that all payments must be collected by the Friday of the week that the child attended in order for the Recreation Department to pick up their child the following Monday. The staff recommends this policy and/or any suggestions the commission has regarding these issues. POWY � Pr ct Oce$Y`131.;r R°SCI(r Ccs i 2. Scholarship Program: Background: Related to the payment policy is the issue that approximately 20% of the children attending the before/after school program are from families that are having a difficult time paying these.fees. Thus,there is a significant need for a scholarship for this tax funded program. The staff has done a survey regarding scholarship programs in the area. Most cities do not have any scholarship programs in effect. Staff spoke to two cities that do have programs in effect. One city uses the free lunch program as their determining criteria and the other city looks at the family's entire situation and makes their decision on a case by case basis. This second approach is a less efficient and time-consuming manner of determining need. For your information, a family of three needs to earn $25,000 per year or less to qualify for the free lunch program. Staff Recommendation: Attached please find the requirements for the free lunch program for the Orange County Schools. Staff believes that the free lunch criteria is the most fair and equitable manner of implementing a scholarship program. Target families and their children could be quickly identified and assistance impartially provided. The staff recommends these policies be adopted. BN/mdb OCOEE RECREATION DEPARTMENT BEFORE/AFTER SCHOOL PROGRAM PAYMENT POLICY PROPOSED PAYMENT POLICY: Payment in full must be made by 6:00 p.m. on the Friday of the week your child attends the program in order for your child to attend t e following week. If payment in full is not received by Friday evenin e person authorized to pick up that child on Friday afternoon will be required to sign a letter acknowledging the non-payment and non-attendance on the following Monday. • OCOEE RECREATION DEPARTMENT SCHOLARSHIP PROGRAM BEFORE/AFTER PROGRAM • DEFINITION: Scholarship program offers children in the before/after school care to have fees waived because of their inability to afford payment of fees. QUALIFICATIONS: (a) The child must be currently on the free lunch program\at their school, or (b) The chil ,is a foster child or ward of the state. c91 JAL filj:D CRITERIA: • Scholarships start on Jan. 1st and run through Dec. 31st • If a child is on the scholarship program and fails to attend for a period of three weeks, the scholarship will be forfeited. • If the child should come back to the program, they must reapply. • -TY)LL,o,-t-- cef ADMINISTRATOR: All decisions will be made by the Recreation Supervisor. SCHOLARSHIP PROGRAM INFORMATION SURVEY 1_WEST ORANGE YMCA FEES: $87.00 per week per child for members $120.00 per child per week for non-members Collected one week in advance HOURS: 7:00a.m. to 6:30 p.m. $5.00 per minute late fee FINANCIAL ASSISTANCE: No child is turned down and charges are based on household income 2. WINTER GARDEN RECREATION DEPARTMENT FEES: $35.00 per week per child for residents $40.00 per child per week for non-residents HOURS: 7:30a.m. to 6:00 p.m. $5.00 per minute late fee FINANCIAL ASSISTANCE: If a child is in the free lunch program they are accepted 3— CITY OF ORLANDO FEES: $40.00 per week per child for residents $50.00 per child per week for non-residents Collected in advance. If parent does not pay, child does not attend. HOURS: 7:30a.m. to 5:30 p.m. FINANCIAL ASSISTANCE: 1. Parent must complete application 2. Must be a City resident 3. If child is a foster child or a ward of the state, fees are automatically waived. 4. If on TANF or food stamps, fees are waived, but must show proof 5. Low income are based on household income and are either reduced 50% or free. 4. CITY OF KISSIMMEE FEES: $110.00 per two week session per child HOURS: 7:00a.m. to 6:00 p.m. FINANCIAL ASSISTANCE: None CITY OF OCOEE RECREATION DEPARTMENT ATHLET=IC FIELD PERMIT 1820 A.D. Mims Road, Ocoee. FL 34761 (407)905-3180 FAX: (407)654-4734 Date of Application: Name: Name of Organization (if applicable): Street Address: Social Security/Federal I.D. #: City: State: Zip Code: Home Phone: Office/Work Phone: Field requested(check eP VIGNETTI SOFTBALL FIELD FREEDOM PK/THRONEBROOKE Day and Dates Requested (HOURS STATED INCLUDE ARRIVAL AND DEPARTURE TIME:) DATE REQUESTED TIME REQUESTED TOTAL HOURS am/pm am/pm FROM TO In consideration of the permission of use granted the rentee by the City of Ocoee,Florida,to use the above listed facilities,the lessee hereby releases the City of Ocoee,its agents,employees and officers from all causes of action,claims or demands which we,our heirs,executors and assignees may have against the City of Ocoee, its agents,employees and/or officers for all personal injuries known or unknown, injuries to property,and damages arising out of the above described activity, even if such injuries are caused by the negligence of the City of Ocoee, its agents,employees and/or officers. I have received,read and understood the Rental Agreement and the Policies and Procedures, and agree to rent the stated facility in accordance with the policies as outlined. LESSEE (PLEASE PRINT) LESSEE SIGNATURE DATE RENTAL FEES (for office use only) FIELD RENTAL FEES - $15 PER HOUR - PER FIELD Total Hours Rental Fee $ Check No. Fee Waived? Cash $ TOTAL $ Receipt No. _ ,5 , ,a l 4 .y .e'4