Summer Camp Scholarship Application Form
Child's Full Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Race Identification (Select one or More)
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
Other
Prefer not to say
Is your child of Hispanic, Latino, or Spanish origin?
Yes
No
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Family Information
Parent 1
Parent Name
First Name
Last Name
Home Phone
Work Phone
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Parent 2 (If necessary)
Parent Name
First Name
Last Name
Home Phone
Work Phone
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Other children in family
Configurable list
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Additional Information
Monthly Family Income (Gross)
$
Is there an amount you could pay for a four-day, 2nd - 6th grade session (cost is $100.00), if applicable?
$
Is there an amount you could pay for a one-night 7th - 12th grade session (cost is $20 each), if applicable?
$
Numbers don't paint the full picture. Can you please tell us a bit about your family situation?
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