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Camp Scholarships Application
Home
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Camp Scholarships Application
Step 1 of 3
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Parent/Guardian Name:
*
First
Last
Email:
*
Phone:
*
Parent / Guardian Occupation
*
Which of the following do you receive?
*
CHIP
Medicaid
Neither
(Select One)
CHIP #:
*
Medicaid #:
*
Child's Name:
*
First
Last
Child's Date of Birth:
*
Date Format: MM slash DD slash YYYY
Child's Last Completed Grade Level:
*
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
What grade will your child have completed by the time camp starts?
Zip Code for Child's Primary Address:
*
What school does your child attend?
*
Most Recent Total Combined Household Income
*
$0 - $9,999
$10,000 - $14,999
$15,000 - $24,999
$25,000 - $49,999
$50,000 - $74,999
$75,000+
Race/Ethnicity: (Optional)
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White (Non-Hispanic)
Check all that apply
Provide Consent
*
I hereby certify that the above statements are true and correct.
Date
*
Date Format: MM slash DD slash YYYY
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Email
This field is for validation purposes and should be left unchanged.
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