Youth Haven Individual Household Application

We are grateful to be able to offer free day camps, overnight or weekend camps, and summer camps for kids who have experienced some type of hardship in their lives. Examples include children in foster care, single-parent homes, or low-income homes. Our day camps and overnight or weekend camps are available for ages 7-13, with longer camps during the summer for ages 8-13. Sponsors provide scholarships so all of these children can attend free of charge.

If you feel your children would benefit from attending our weekend or summer camps and qualify to receive full scholarships, please completely fill out the information below and click "Submit" at the end of the form. This helps us to ensure we are helping those children and families who truly need it. Thank you!

First Name Last Name

Street Address

Street Address Line 2

City State

Zip Code

Street Address

Street Address Line 2

City State

Zip Code

Area Code Phone Number

Single Married Divorced Separated

Please Note: When children come to Youth Haven, they will participate in camp activities as a team of five or six, as well as in large groups for our all-camp activities. To help ensure a safe and successful experience for everyone, children need to be able to function in small groups and larger group settings; we are not staffed to provide constant one-on-one care. Thank you for your understanding.

First Name Last Name

Gender Date of Birth

First Name Last Name

Gender Date of Birth

First Name Last Name

Gender Date of Birth

First Name Last Name

Gender Date of Birth

First Name Last Name

Gender Date of Birth

First Name Last Name

Gender Date of Birth

Full Name Relationship to Children

Less than $12,000 Between $12,000 - $17,999 Between $18,000 - $23,999 Between $24,000 - $34,999 Between $35,000 - $49,999 Greater than $50,000

Every Week At Least Once a Month Occasionally Only on Holidays

Youth Haven is a non-denominational Christian outreach.
PO Box 97, Rives Junction, MI 49277
PO Box 716, Eloy, AZ 85131
www.youthhaven.org

Individual Household Application

Parent/Guardian Information

Information on Children

Household Information

Summary of Need

Verification