HomeMy WebLinkAboutFinancialAssistance
POLLOCK COMMUNITY WATER PARK
2026 FINANCIAL ASSISTANCE APPLICATION
All information shall be filled in legibly AND SUPPORTING DOCUMENTATION ATTACHED or the application
will not be considered for assistance. Application deadline is Friday, May 1, 2026. Qualifying applicants will
be randomly chosen until available funding is exhausted. City of Oshkosh Residents receive priority in
selection. If chosen for assistance applicants will be notified in May.
PASS TYPE REQUESTED
☐ Family Pass ☐ Senior (60+) ☐ Adult (18-59) ☐ Youth (3-17) ☐ Infant (0-2)
HEAD OF HOUSEHOLD INFORMATION
_____________________________________________________________________________________
Name: First, Last Phone Number Email
_____________________________________________________________________________________________
Address City State Zip
EMERGENCY CONTACT INFORMATION
_____________________________________________________________________________________
Name/Relation Phone Number Email
_____________________________________________________________________________________________
Address City State Zip
APPLICANT INFORMATION
ALL those that wish to secure a pass shall have their names listed below. Please note that a family pass is limited to 2 adults only.
NAME BIRTH DATE GENDER
1. _______________________________________ _______________________ ☐ M / ☐ F
2. _______________________________________ _______________________ ☐ M / ☐ F
3. _______________________________________ _______________________ ☐ M / ☐ F
4. _______________________________________ _______________________ ☐ M / ☐ F
5. _______________________________________ _______________________ ☐ M / ☐ F
6. _______________________________________ _______________________ ☐ M / ☐ F
7. _______________________________________ _______________________ ☐ M / ☐ F
8. _______________________________________ _______________________ ☐ M / ☐ F
CITY OF OSHKOSH – DEPARTMENT OF PARKS
805 WITZEL AVE, OSHKOSH, WISCONSIN 54902
PHONE: (920) 236-5080
FINANCIAL ASSISTANCE APPLICATION: Update 12/2025
ELIGIBILITY QUALIFICATIONS
The information requested below is confidential and is necessary to help determine the degree of need for each applicant.
A. The above family currently qualifies for free or reduced lunch at school: ☐ YES* / ☐ NO
* If yes, please submit the letter you received from the Oshkosh Area School District that proves eligibility for the free or reduced
food program through June 20XX.
B. Total Household Income & Income Eligibility Guidelines. You must tell us how much and how often.
NOTE: Income levels will be compared to State’s Income Eligibility Guidelines (attached). Please provide
proof of income for all household members. If no income, please make the proper notation.
Name (first, last)
(list everyone in household)
Earnings from
Work Before
deductions
Welfare, child,
support, alimony
Pensions,
retirement, Social
Security
Other Check if NO
income
1. __________________________ $_______ /_______ $_______ /_______ $_______ /_______ $_______ /_______ ☐
2. __________________________ $_______ /_______ $_______ /_______ $_______ /_______ $_______ /_______ ☐
3. __________________________ $_______ /_______ $_______ /_______ $_______ /_______ $_______ /_______ ☐
4. __________________________ $_______ /_______ $_______ /_______ $_______ /_______ $_______ /_______ ☐
5. __________________________ $_______ /_______ $_______ /_______ $_______ /_______ $_______ /_______ ☐
6. __________________________ $_______ /_______ $_______ /_______ $_______ /_______ $_______ /_______ ☐
SIGNATURE
The undersigned hereby affirms that the above information is true and correct and he/she understands and will
abide by the facility’s regulations. Furthermore, he/she will abide by and conform to all ordinances of the City of
Oshkosh.
________________________________________________
Applicant Name (Print)
_____________________________________________________________________________________________
Applicant Signature Date
(Shall be 18 years or over)
______________________________________________________________________________________________________
FOR OFFICE USE ONLY
Income Eligibility Guidelines
July 1, 2025, to June 30, 2026