Scholarship Application | Camp Seymour/Camp Lake Helena

Name* This field is required.

First Name

Last Name

Email* This field is required.

example@example.com

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Phone Number* This field is required.

Area Code

Phone Number

Address* This field is required.

Street Address

Street Address Line 2

City

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Number of additional persons living in this household* This field is required.A household is defined as any adult(s) living together with dependents.

Additional Information for Primary Applicant* This field is required.

Date of Birth (00/00/0000)

Age

Type of Income

Gross Monthly Amount

Additional Member of the Household #1

First Name

Last Name

Relationship to Applicant

Gender

Date of Birth (00/00/0000)

Age

Type of Income

Gross Monthly Amount

Additional Member of the Household #2

First Name

Last Name

Relationship to Applicant

Gender

Date of Birth (00/00/0000)

Age

Type of Income

Gross Monthly Amount

Additional Member of the Household #3

First Name

Last Name

Relationship to Applicant

Gender

Date of Birth (00/00/0000)

Age

Type of Income

Gross Monthly Amount

Additional Member of the Household #4

First Name

Last Name

Relationship to Applicant

Gender

Date of Birth (00/00/0000)

Age

Type of Income

Gross Monthly Amount

Additional Member of the Household #5

First Name

Last Name

Relationship to Applicant

Gender

Date of Birth (00/00/0000)

Age

Type of Income

Gross Monthly Amount

Additional Member of the Household #6

First Name

Last Name

Relationship to Applicant

Gender

Date of Birth (00/00/0000)

Age

Type of Income

Gross Monthly Amount

Documentation* This field is required.Please provide all documents that pertain to your household to expedite the process.

REQUIRED: Two months of bank statements

REQUIRED: Two months of recent pay stubs for all household members from every employer (if unemployed, current unemployment benefits statement)

Child Support verification, or proof of non-support. Could include bank statements or letter from parent

LES - for military personnel, including housing and food allowances

If self-employed, current profit and loss or balance sheet

SSA or SSI award letter

Statement of monthly pension, annuity, and/or all other retirement income

DSHS or TANF award letter detailing cash and food assistance, including household income page (supplemented with other income or WorkSource letter)

Notice from Pierce County Housing Authority or Kitsap County Housing Authority

New hires: official letter from employer verifying monthly income

Full-time student proof of enrollment and financial aid award letter

Please upload document(s) noted above* This field is required.You may upload original files or photos of the documents.

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Max. file size: 10.0MB

Tell Us MorePlease share any additional information not included on this form, if appropriate. Examples include medical bills, education expenses, and recent changes in employment. Please upload supporting documents on the following page.

My signature, below, certifies I have read and understand the following: (1) I have provided all requested information that applies to me and my household members. (2) I have provided verification of income of all household members with the most recent two months' pay stubs and/or all other income and bank statements. (3) If I have any dependent children listed, I have provided verification of recent child support payments or verification that I do not receive child support (contact Division of Child Support Enforcement at 253-597-3700). (4) I have provided supporting documentation for the extenuating circumstances described above. (4) I understand this application will be voided 30 days after the review is completed if I do not enroll in a Child Care program at the Y. (5) I understand that the scholarship will expire and the rate will be raised to the full Child Care rate if the review paperwork is not turned in before the expiration date. (6) I understand that scholarships do not apply to drop-in, registration, or late fees.

I declare the statements above are true and complete to the best of my knowledge. I understand any misrepresentation on my part may disqualify me from receiving a Y Experience Scholarship. I hereby authorize verification of information given, and I agree to provide any and all requested information needed to evaluate my need for financial assistance. I understand a review of my financial situation and circumstances will be periodically conducted at the request of the Y to verify my continuing need for assistance.

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Scholarship Application | Camp Seymour/Camp Lake Helena