CAMP AUTHORIZATION FORM

CAMP AUTHORIZATION FORM
Camp assistance may be provided to eligible families on a first-come, first-served basis. Funds will be deducted from your annual Cuyahoga DD Family Supports Program funding.

If you have any issues or questions about this form, please contact NEON at 330-792-6413
CAMPER INFORMATION
Camper's Name:*

First NameLast Name
Camper Date of Birth:*

MonthDayYear
Date
Current Age:*
Parent/Guardian Name:*

Parent First NameParent Last Name
Address*

Street Address (Include Apt #, PO box, Up/Down, etc)

Street Address Line 2

CityState

Zip Code
Parent/Guardian Phone Number:*
Please enter a valid phone number.
Parent/Guardian Email address:*

Confirmation Emailexample@example.com
CAMP INFORMATION
Name of Camp:*
Camp placement confirmed?*

YesNo
Camp address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Camp Contact Person:*
Camp Phone Number:*
Please enter a valid phone number.
Camp Email Address:
Enter the Camp email address for quicker processing times
Camp Start Date:*

MonthDayYear
Date
Camp End Date:*

MonthDayYear
Date
OTHER INFORMATION
Camper's School District:*
Has Extended School Year (ESY) service been authorized? (If your child qualifies for ESY, we expect that you will use those funds first prior to requesting additional camp funds from your FSP allotment):*

YesNo
Amount requested from the Family Supports Program per WEEK of camp*:*
*Registration fees, before or after care programs, and transportation cannot be funded through the Family Supports Program
Number of weeks requested:*
TOTAL amount requested from Family Supports Program yearly allocation:
If you receive an error message, please correct the amount requested per WEEK and/or the number of weeks requested, as this total auto populates based on # of weeks requested and amount per week
TOTAL1 amount requested from Family Supports Program yearly allocation:
Additional Comments (if any):

0/100
Parent/Guardian Signature:*

Clear
Submission Date:

YearMonthDay
Date
Note to Camps: Please send the invoice to NEON within 4 weeks of the conclusion of the camp session. Payment will be remitted at that time. Final date for acceptance of camp invoices is October 31st.
Below information will be completed by NEON staff
Amount to be paid by CCBDD:
To be completed by NEON
Approved by:
NEON staff
Date emailed to camp:

MonthDayYear
Date
Date emailed to family:

MonthDayYear
Date
Should be Empty:

CAMP AUTHORIZATION FORM

CAMPER INFORMATION

CAMP INFORMATION

OTHER INFORMATION