Fred L. Waterman Conservation Education Center

Summer Day Camp Scholarship Application

Child's Name ____________________________ Age_________ Sex______

Parent(s) Name(s)_________________________________________________

Address __________________________________________________________

Telephone: (home)________________ (work) __________________

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 or 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 Education Center permission to verify it.

Signature ___________________________________ Date ___________________

Parent or Guardian