Summer Day Camp Scholarship Application

Child’s Name ____________________________________ Age____________ Sex: M F

Parent’s Names _____________________________________________________________

Address____________________________________________________________________

Telephone: (home) _______________ (work) ________________ (cell)_________________

The following information is required to receive scholarship aid. All information will be kept

strictly confidential. Scholarships will be awarded on the basis of financial need, desire,

recommendations and/or referral. Due to the limited number of scholarships available this year,

they will be awarded on a first come, first awarded basis.

Gross income: Monthly __________________ Weekly ________________

Is income source Welfare? _________ If yes, what type? _____________________

Number in family? ____________________ Is the applying child a foster child? _______

Employers: ________________________________________________________________

Father Mother

Employers’ Addresses: _______________________________________________________

Father Mother

Employers’ Telephone: _______________________________________________________

Father Mother

How long have you been employed here? Father _____________ Mother __________

Does your child have any medical physical problems? If yes, please explain on the back of this form.

I hereby certify that all the above information is true and correct. I understand that this

information is being given in confidentiality and I give Waterman Conservation

Education Center permission to verify it.

Signature _______________________________________ Date __________________

Parent or Guardian