Campership Application
Scholarship funds are available to persons with intellectual and developmental disabilities and their family members residing in Mower County only who need assistance with the cost of the activity for which the funds are requested for. Scholarships may be requested for camp, vacation and training/educational opportunities. There will be a $100.00 limit per year/per person. The scholarship fund is limited. This program is funded through donations received at LIFE Mower County. Applications for scholarships must be submitted on this form. Requests for funds can be made by the individual, parent, guardian or support staff.
Name of Applicant
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Name of person requesting funds
*
First Name
Last Name
Relationship to applicant
*
Amount requested
*
Total cost of activity
*
Purpose for funds needed
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Date funds needed by
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Month
-
Day
Year
Date
Check payable to
*
Address check should be mailed to
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please fill out other sources of income below. Other sources of Income: (Example: Personal Money, Money from Parents, Gifts, Etc)
*
Total
Wages
Personal Money
Gifts
Social Security
Other Money
Submit
Should be Empty: