Summer Camp Scholarship Form

Child's Name*
Child's Date of Birth*
Parent/Guardian Contact Information
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Phone*
Camp Options
Please note the top three camp choices for your child. Scholarships are given based on availability of the camp at the time the scholarship is approved. Camp preferences are not guaranteed.
Camp #1
Camp #2
Camp #3
Household Information
Number of adults living in the household?*
Number of children living in the household?*
Please select the category which indicates the total family income for the previous year.*
Please list all allergies, plus reaction and treatment.
Please list any medical conditions that are pertinent to their camp experience.
Please list any dietary restrictions.
Is there anything we need to know about your child to ensure s/he has the best possible experience?
Consent*
By submitting this form, I agree the terms and conditions of the Miriam P. Brenner Children's Museum. I understand that if the child indicated above receives a summer camp scholarship, I am responsible for transportation to and from camp. Extended care during camp season is not available. I understand that the scholarship is not transferrable. The Miriam P. Brenner's Children's Museum will contact the parent or guardian of the scholarship recipient no later than two weeks prior to camp commencing. Please direct all inquiries to 336.574.2898 ext. 302 or [email protected].
Signature of Parent/Guardian*

Type to Sign

Summer Camp Scholarship Form

Summer Camp Scholarship Form

Parent/Guardian Contact Information

Camp Options

Household Information