V2 South Shore YMCA, Camp Burgess & Hayward Financial Assistance Application

South Shore YMCA, Camp Burgess & Hayward Financial Assistance Application
CAMP FILLS QUICKLY! If you haven't already registered for camp, please call our office at 508-428-2571 to check availability before filling out this form. All forms must be fully completed by April 15th 2024.

Please reach out to us with any questions at 508-428-2571 or at camp@ssymca.org. If you would prefer to submit your application by mail, please click this link and print out the form. Mail the completed form to: 75 Stowe Rd Sandwich MA, 02563.

Please note: financial assistance is available for a maximum of two weeks of programming per child, per summer.

Household information
Parent/Guardian Name*

First NameLast Name
Household Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Number of People in Household:

Please list all people living in your household, including yourself*

	Name	Current Age	Name of Employer/School
1
2
3
4
5
6
7

Have you ever applied for financial assistance before from Camp Burgess & Hayward?*

YesNo
If Yes, How much did you previously receive per Child in 2023
If Yes, How much did you previously receive per Child in 2022

Camper(s) Information
Participant #1
Name of Participant #1*

First NameLast Name
Gender of participant #1*
Date of Birth of participant #1*

MonthDayYear
Date
Session attending for participant #1*
Is Participant #1 attending another camp session?*

YesNo
Additional session attending for participant #1*
Is Participant #1 attending another camp session?*

YesNo
Additional session attending for participant #1*
Is Participant #1 attending another camp session?*

YesNo
Additional session attending for participant #1*
Do you have another child attending camp?

YesNo
Participant #2
Name of Participant #2*

First NameLast Name
Gender of participant #2*
Date of Birth of participant #2*

MonthDayYear
Date
Session attending for participant #2*
Is Participant #2 attending another camp session?*

YesNo
Additional session attending for participant #2
Is Participant #2 attending another camp session?*

YesNo
Additional session attending for participant #2
Is Participant #2 attending another camp session?*

YesNo
Additional session attending for participant #2
Do you have another child attending camp?*

YesNo
Participant #3
Name of Participant #3*

First NameLast Name
Gender of participant #3*
Date of Birth of participant #3*

MonthDayYear
Date
Session attending for participant #3*
Is Participant #3 attending another camp session?*

YesNo
Additional session attending for participant #3
Is Participant #3 attending another camp session?*

YesNo
Additional session attending for participant #3
Is Participant #3 attending another camp session?*

YesNo
Additional session attending for participant #3
Do you have another child attending camp?*

YesNo
Participant #4
Name of Participant #4*

First NameLast Name
Gender of participant #4*
Date of Birth of participant #4*

MonthDayYear
Date
Session attending for participant #4*
Is Participant #4 attending another camp session?*

YesNo
Additional session attending for participant #4
Is Participant #4 attending another camp session?*

YesNo
Additional session attending for participant #4
Is Participant #4 attending another camp session?*

YesNo
Additional session attending for participant #4

Financial Information

Please itemize you monthly, pre-tax income and expenses
Monthly Pre-tax Income
Monthly Gross Wage/Salary (household)*
Monthly Child Support
Monthly Social Security
Monthly Food Stamps
Monthly Retirement Income (non-social security)
Other Monthly Income
Please explain other monthly income
Total Monthly Income
Monthly Pre-tax Expenses
Monthly Rent/mortgage
Monthly Food
Monthly Medical
Monthly Utilities
Monthly Car
Monthly Tuition
Other Monthly Expenses
Please Explain Other Monthly Expenses
How much can you afford to pay towards this summer's program (per child)?*
Financial Records

When submitting these documents, please make sure to black out your Social Security number if present on the forms
Upload a copy of your most recent federal income tax form (Form 1040, only page 1 & 2)*

Cancelof
Upload a recent pay stub, verification of income, or proof of unemployment*

Cancelof

Please explain why you are applying for Financial Assistance. If your child/ren is a returning participant, please tell us how our programs have been beneficial and impactful to you and your child/ren*
We are working to gather stories of impact that relay the good work that we do!Would you be willing to share your Family's Camp Burgess & Hayward story with us to help us garner support for our Campership Fund?

Yes I would like to share our story - Feel free to quote what I've written hereYes, I would like to share out Story - but please keep it anonymousNo, I do not want to share our story

Financial Assistance Deposit

If you did not register and pay a deposit online, you must pay a $50 deposit per participant, per program/session
Payment Method

I will pay by check I will mail in a check to cover the financial aid deposit to: 75 Stowe Rd Sandwich MA 02563I will pay by credit cardI already registered online
Name on Credit Card*

First NameLast Name
Credit Card Number*
CVV*
Expiration Date*

Parent/Guardian Signature*

Clear
Name*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty:

South Shore YMCA, Camp Burgess & Hayward Financial Assistance Application

Household information

Camper(s) Information

Participant #1

Participant #2

Participant #3

Participant #4

Financial Information

Monthly Pre-tax Income

Monthly Pre-tax Expenses

Financial Assistance Deposit