Underserved and Rural Youth Campership Award for Youth Ages 6-17
Confidential Application: The information in this application is reviewed by the grant committee without camper of parent/guardian names and applications are deleted once recipients have been determined. We are currently unable to serve youth who are at risk of harm to themselves or others.
Applicant Information (Youth/Camper)
Camper Age at Time of Camp Session
Camper City of Residence
Camper School of Attendance in Spring of 2021
Applicant Information (Parent/Guardian)
Street Address Line 2
State / Province
Postal / Zip Code
Parent/Guardian Phone Number
Please enter a valid phone number.
Household income Per Year
$10,000 or Less
$10,000 - $20,000
$20,000 - $30,000
$30,000 - $40,000
$40,000 - $50,000
$50,000 - $60,000
$60,000 - $70,000
$70,000 - $80,000
Number of ADULTS supported by the above income.
Number of YOUTH under 18 supported by the above income.
Youth/Camper Demographic Information
This information is confidential and is collected anonymously and stored statistically as required by the grant program.
Check all that apply to the youth/camper (confidential)
Rural Youth (housing is 5 or more miles outside of the limits of any city)
Identifies as LGBTQ
Living with guardian other than biological parents
Biological parent incarcerated or in drug treatment
Please share any family circumstances that support the camper's need for this scholarship.
Session Choice: If chosen for the Camperhip Award, my camper would like to attend the following session:
Day Camp 1 (Ages 6-12): July 19th - 23rd
Day Camp 2 (Ages 6-12): July 26th - 30th
Day Camp Service Learning and Leadership 1 (Ages 13-17): July 19th - 23rd
Day Camp Service Learning and Leadership 2 (Ages 13-17): July 26th - 30th
Mini-Camp (Overnight, two-nights, ages 6-12): August 4th - 6th
Resident Camp 1 (Ages 6-12): August 8th - 13th
Resident Camp Service Learning and Leadership 1 (Ages 13-17): August 8th - 13th
Resident Camp 2 (Ages 6-12): August 15th - 20th
Resident Camp Service Learning and Leadership 2 (Ages 13-17): August 15th - 20th
Teen Adventure Camp (Ages 13-17) OFFSITE, TRAVELING IN VANS, CENTRAL OREGON CASCADES, CAMPING, BOATING, HIKING: August 22nd - August 27th
Transportation Need - Available in Lane County Only (Check all the apply)
We will need assistance with transportation to and from camp.
We will transport the camper to and from camp ourselves.
We will carpool to and from camp with another family.
Supplies Needed (Check all supplies that the camper will need assistance procuring)
Sleeping Bag (Overnight Only)
Headlamp/Flashlight (Overnight Only)
Commitment to Attend
If awarded this scholarship, it will be in place of another application. The following questions are meant to express your commitment to support the camper/youth in attending the program.
I will personally support the camper in attending the program.
It is my belief that the youth for whom I am applying WANTS to come to camp.
I believe the youth for whom I am applying will benefit from camp because:
Where did you hear about this opportunity?
School Guidance Counselor
I was forwarded an email.
If you selected "other" please tell us how you heard about this opportunity.
I HEREBY ATTEST THAT THE INFORMATION IN THIS APPLICATION IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE.
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