PO Box 1932, Basalt, CO 81621
Email: Website:
PLEASE NOTE: Registration is not complete until ALL required documentation, including payment, has been received. We are sorry, but we are unable to place your child on a team until all items have been received.
All documentation must be received by June 20, 2014 to be eligible for scholarship consideration.
Date: ______
Applicant’s Name: ______D.O.B ______M/F (Circle)
Best Email address: ______Best Phone Number:______
Reason for scholarship request: ______
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For more room to write, please continue on another page.
Have you asked for a scholarship in the past? Yes No (Circle One)
Have you received a scholarship in the past? Yes No (Circle One) How many times?______
All scholarship players (and/or parents) are required to volunteer 8 – 10 hours per season.
Please indicate the area(s) you are willing to assist with (check all that apply):
Concession Sales _____ Field Work _____ Communications/Media _____ Gear Swap _____ Tournament ______
Fundraising ____ Translation/Hispanic liaison _____ Head Coach _____ Asst. Coach _____ Team Manager _____ Center Referee ____ Linesman ___ Board Member ___ Other (describe):______
What Club volunteer activities did you participate in last year: ______
Financial Statement (please use the reverse side to describe any special circumstances):
What is the total annual income for your family? ______
What is your monthly mortgage or rent payment? ______
What is your monthly car payment(s)? ______
Please list the total of your other monthly payments: ______
Number of children under age 18 living at home: ______Number of children enrolled in BSC: ______
What age group will your child(ren) be playing (please include payment with application):
_____ U18 (14-17 years old as of July 31, 2014) reduced fee is $50 Deposit
_____ U14 (12 or 13 years old as of July 31, 2014) reduced fee is $100
_____ U12 (10 or 11 years old as of July 31, 2014) reduced fee is $100
_____ U10 (8 or 9 years old as of July 31, 2014) reduced fee is $80
_____ U8 (6 or 7 years old as of July 31, 2014) reduced fee is $60
_____ U6 (4 or 5 years old as of July 31, 2014) reduced fee is $40
The following items are required to finalize the registration process:
______Completed registration form (online or by mail)
______Completed Scholarship Application, with Financial Statement
______Payment (if you have received a scholarship in the past, please consider paying more than the reduced fee)
Please mail the completed Scholarship form to the address above. A Registration form may be included, or completed online at The Scholarship Application will be viewed by the Basalt Soccer Club Scholarship Committee and will be kept strictly confidential within the Basalt Soccer Club. You may request a payment refund if you are not awarded a scholarship, or space is not available for your child. Have questions? Please contact us at
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