Camp Scholarship Application
Applicants Must Be Somers Residents
Name of Person Completing Form
*
First Name
Last Name
Gender
Male
Female
Relationship to Child/ren
*
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Family Information
Spouse's Name
First Name
Last Name
Occupation/Work Status
*
Dependent 1
*
First Name
Last Name
Gender/Age/Grade Entering Sept 2026
*
Dependent 2
First Name
Last Name
Gender/Age/Grade Entering 2026
Dependent 3
First Name
Last Name
Gender/Age/Grade Entering 2026
Dependent 4
First Name
Last Name
Gender/Age/Grade Entering 2026
Monthly Income from All Sources
Include gross monthly earning before deductions, monthly welfare, child support, pensions, Social Security, Disability, etc. Please be aware that additional back up documentation must be supplied upon request.
Family Member 1
*
First Name
Last Name
Monthly Income
*
Family Member 2
*
First Name
Last Name
Monthly Income
*
Family Member 3
*
First Name
Last Name
Monthly Income
Special Considerations (Unusual expenses, Family circumstances, Medical, etc.) Must Be Filled Out
*
Scholarship Request(s)
Child 1
*
First Name
Last Name
Camp For The Blind/Town Camp
*
Child 2
First Name
Last Name
Camp For The Blind/Town Camp
Child 3
First Name
Last Name
Camp For The Blind/Town Camp
Child 4
First Name
Last Name
Camp For The Blind/Town Camp
I certify that the above information is true and correct
*
Applicants need to register with the Somers Parks & Rec Dept
Please verify that you are human
*
Submit
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