2020 Camp Financial Assistance Application (Full)

Pompositticut Farm Day Camp Financial Assistance Application

Summer 2025
Name of Camper

First NameLast Name
Male / Female

MaleFemale
Date of Birth

MonthDayYear
Date
Current Grade
Is your child on an IEP or 504 Plan?

YesNo
Legal Custodian

First NameLast Name
Phone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Does the applied camper live reside with the legal custodian at the above address?

YesNo
Have you applied for a camp session on our online system?

YesNo
Please indicate which session you have interest in receiving financial assistance for.

June 28- July 3, 2025July 7 -July 18, 2025July 21 - August 1, 2025August 4- August 15, 2025Any Available Session- Best Option
To be Completed by Parent / Guardian
Please make a brief statement describing why your child is in need of financial assistance.
To be Completed by Parent / Guardian
What is your occupation / job title?
What is Parent 2's occupation?

What is the combined/total annual household income: Check the appropriate box.

	Under $20,000	$20,000-$30,000	$30,000-$40,000	$40,000 and Up
Income

Total Income
Number of Dependents currently living in your household?
List Special Circumstances (If Any)
Do you have other children you'd like to attend camp this year?

YesNo
If yes, please provide the other Child's Name, Birthdate, Age and if they are on a IEP/504 plan below.
By signing this document, I agree that the information is accurate.
Parent / Guardian Name

First NameLast Name
To complete this application you must mail a copy of the front page of your 1040 tax form, along with the two most recent pay stubs and/or copies of any government subsidies.

Mailing address: Pompositticut Farm Day Camp, 25 Lewis St, Hudson MA 01749
Parent / Guardian Signature

Powered by Jotform SignClear
References

To be completed by someone other than a family member. (Ex. Teacher, School Administrator, Scout Leader, Pastor, etc.) Please include a brief statement made by the reference of your choosing, a reference signature, and the relationship to the child.

Please make a brief statement describing why this child deserves a scholarship.

References can be mailed, emailed to mail@pompositticutfarm.com or uploaded below.
Recommendation Letter One:

Cancelof
Please Note: Financial assistance is not guaranteed. It will be determined based on the viability of your application. Assistance will be given based on the availability of funds and level of need.

Please write a descriptive account of why your child is in need of financial assistance.

This application is confidential. The information on the form will not be disseminated.

Once your application is reviewed you will contacted by our management team within 2 weeks.

The finanical assistance decision will be finalized within 3-4 weeks of submitting the application.

Limited financial spots per sessions, completed applications are considered in order they are recieved.
Should be Empty:

Pompositticut Farm Day Camp Financial Assistance Application

To be Completed by Parent / Guardian

To complete this application you must mail a copy of the front page of your 1040 tax form, along with the two most recent pay stubs and/or copies of any government subsidies.