Scholarship Application form

Parent #1 Information:

First Name
Last Name
Employer
Job Title
City of Residence
Religion Jewish Other
Synagogue Affiliation
Marital Status

  
Parent #2 Information:

First Name
Last Name
Employer
Job Title
City Of Residence
Religion Jewish Other
Synagogue Affiliation
Marital Status


Child #1 Information:
Please fill out the following section separately for each child applying

First Name
Last Name
Date of Birth (mm/dd/yyyy)
Grade (Fall 2014)
Did you receive a camp scholarship for 2012? Yes No Unsure
If yes, please list amount

If applying for only one child please continue here, if applying for multiple children please continue below.
  
Child #2 Information:

First Name
Last Name
Date of Birth (mm/dd/yyyy)
Grade (Fall 2014)
Did you receive a camp scholarship for 2012? Yes No Unsure
If yes, please list amount

Child #3 Information:

First Name
Last Name
Date of Birth (mm/dd/yyyy)
Grade (Fall 2014)
Did you receive a camp scholarship for 2012? Yes No Unsure
If yes, please list amount

 

Financial Information:
Parent(s) claiming the applicant for tax purposes (2010 Tax returns are required). Please answer these questions as listed on your tax returns. 

2012 federal tax return:  Adjusted gross income
2012 federal tax return:
Filing status
Total number of exemptions claimed (Line 6D on your 1040 returns)
# of Children in family
# of Adults in family

Statement of Need:
Describe any special expenses or changes in family or economic circumstances over the past year that support your request for financial aid this year. Include known events in 2014 that will impact your family. (new child, bar mitzvah, etc). Please mention if you are a single parent, first generation émigré, special needs family member, or have multiple children attending. OR if a parent has lost their job or work hours were reduced, please indicate the date, the estimated cost of this change, and which parent (one or both parents) was effected. The more details you provide, the better our committee can understand your situation.

 

Tuition Fees Information:

Amount of full tuition
What can you pay towards camp tuition?
How much can you receive from friends or family?
Please explain source
Funding from any other agencies or grants
Please explain source
Total amount requested


I confirm that all the information contained above is accurate to the best of my knowledge and I understand that if this information is found to be false I may be disqualified from receiving aid and may be required to return any funds received.

Signature  Date 
Email (If you would like receive an email confirmation and receipt)