Summer Camp Scholarship Form

"*" indicates required fields

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*

Please identify 2nd guardian and/or emergency contact

Name*

First Last

Phone*

If you have additional caregivers you wish to list for pickup, please list their first/last name and phone number below:

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?

Signature of Parent/Guardian*

Type to Sign