Mantua Powelton Alliance Summer Camp Financial Assistance Application
Important Notice — This is a pilot program and resources are limited. Families are expected to contribute $10 per week toward the cost of their child's summer camp placement. Submitting this form does not guarantee enrollment. Families will be contacted by MPA staff to confirm eligibility and placement. Only community members residing in Mantua and Powelton Village are eligible to apply.
Parent / Caregiver Information
First Name
*
Last Name
*
Relationship to Child
*
Please Select
Mother
Father
Guardian
Grandparent
Other
Preferred Contact Method
*
Please Select
Phone
Email
Text Message
Other
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Street Address
*
Apartment / Unit
City
*
ZIP Code
*
Select your neighborhood
*
Please Select
Mantua
Powelton Village
Child Information
Child's First Name
*
Child's Last Name
*
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
*
Gender
Please Select
Female
Male
Non-binary
Prefer not to say
Other
Current Grade
*
Please Select
Pre-K
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Other
School Currently Attending
*
Special needs, allergies, or medical considerations (optional)
Summer Camp Program Selection
Preferred Summer Camp Provider
*
Please Select
James Wright Recreation Center
Mantua Urban Peace Garden - Garden Sprouts
Curio Theater
Other Program
If you selected Other, What is the Program Name?
Program Address
Program Telephone
Please enter a valid phone number.
Format: (000) 000-0000.
Second-choice program
Please Select
James Wright Recreation Center
Mantua Urban Peace Garden - Garden Sprouts
Curio Theater
Household Information
(Optional)
Number of children in household
Total household size
Child currently recipient of:
Free/reduced meals
SNAP/ Food Stamps
TANF/ Cash Assistance
Medicaid/ CHIP
Foster care
None of the Above
Other
Anything else MPA should know?
Acknowledgments, Consent & Signature
I understand this is a pilot program with limited resources and that my family is expected to contribute $10 per week toward summer camp costs. Submission does not guarantee placement.
*
Yes
I agree to be contacted by Mantua Powelton Alliance regarding my application and any follow-up information needed.
*
Yes
Submit Application
Should be Empty: