2017 Camp Season
Dear Financial Assistance Applicant:
Thank you for your interest in Camp Eastside. The goal of our Annual Campaign is to help as many children as possible have a camp experience. Please review the below information and submit a completed application with all supporting documentation.
PLEASE BE AWARE OF THE FOLLOWING:
1. Financial Assistance is available for:
a. Up to two sessions of Preschool, Traditional School-Age Camp, Sports Camps or Aquatic Adventure club per child.
2. Each applicant will be asked to pay at least a minimum of:
a. $45 per session for Camp
3. The Deposit is required along with registration form to hold participant’s spot. Financial assistance applications and all supporting documentation are due no later than May 1st.
4. Each YMCA of Greater Rochester branch & overnight camp provides Financial Assistance independently.
5. A short essay is required on how Camp Eastside affects your child(ren).
THE APPLICATION PROCESS
1. Complete the Financial Assistance Cover Page and attach to front of application.
2. Complete the Camp Registration Form for each child that will attend camp.
3. Fill out one Financial Assistance Application per family.
4. Attach all supporting documentation.
a. 2016 Federal Tax Return.
b. Four current paystubs per each working adult
c. Any other supporting documentation that applies (Food Stamp, Housing, Unemployment, Disability, Child Support, Social Security)
5. Enclose required deposit and registration fees. This charge is refundable if you do not qualify for assistance.
a. Camp Registration Fee of $25 per child or $40 per family.
b. $10 deposit for sessions 1-8 and $20 deposit for sessions 9 & 10 per session/per child.
Please submit completed application:
Via Mail:
Eastside YMCA
Attn: Leslie Ristaneo
1835 Nine Mile Point Road
Penfield, NY 14526
Via YMCA: Hand it in at the front desk to Leslie Ristaneo’s attention
Via E-mail:
If you have any questions, email or please call 585-341-4031.
Sincerely,
Financial Assistance Specialist
Eastside Family YMCA
Camp Eastside – 2017
Confidential
FINANCIAL ASSISTANCE APPLICATION
COVER PAGE
(Attach to Complete Application)
Date Submitted: ______
Do you currently have a YMCA Membership? o Yes o No YMCA Branch:______
*Child First Name: ______*Child Last Name: ______*DOB___/___/___
*Child First Name: ______*Child Last Name: ______*DOB___/___/___
*Child First Name: ______*Child Last Name: ______*DOB___/___/___
*Parent/Guardian First Name: ______*Last Name______*DOB___/___/___
*Family Income: $______Total number living in household: ______
*Applying for Campership through DSS: o Yes o No *Required Fields
Check List for Financial Assistance: (All parts of application must be included or application will be considered incomplete and will not be processed.)
o Financial Assistance Cover Page
o Camper Registration Form o Attached oSubmitted Online __/__/__
o 2016 Federal Tax Return
o Four current pay stubs
o Complete Financial Assistance Application – All parts completed with supporting documents
o Camp Registration Fees & deposits
o Short Essay written by child or parent
Financial Assistance Application - 2017
All information listed below will be held confidential.
Only children who are born to you, legally adopted/guardianed by you, and claimable on your taxes will be considered dependents for financial assistance.
Child’s Information 1
Last Name: ______First Name: ______Middle Initial: _____
Birth date: ____/___/___ Age: _____ Gender: oM oF Home Phone: ______
Address: ______City: ______State: _____ Zip: ______
Child’s Information 2
Last Name: ______First Name: ______Middle Initial: _____
Birth date: ____/___/___ Age: _____ Gender: oM oF Home Phone: ______
Address: ______City: ______State: _____ Zip: ______
Child’s Information 3
Last Name: ______First Name: ______Middle Initial: _____
Birth date: ____/___/___ Age: _____ Gender: oM oF Home Phone: ______
Address: ______City: ______State: _____ Zip: ______
Head of Household Information
Relation to Campers: ______Gender: o Male o Female
First Name: ______Last Name: ______Birth date: _____/_____/_____
Home Phone: (____) ______Work Phone: (___) ______Cell Phone: (___) ______
Address: ______
City: ______State: ______Zip: ______
Marital Status: o Single oMarried oSeparated o Divorced o Widowed
Employer: ______Job Title: ______Length of Employment: ____
Work Address: ______
City: ______State: ______Zip: ______
Spouse Information
Relation to Campers: ______Gender: o Male o Female
First Name: ______Last Name: ______Birth date: _____/_____/_____
Home Phone: (____) ______Work Phone: (___) ______Cell Phone: (___) ______
Address: ______
City: ______State: ______Zip: ______
Marital Status: o Single oMarried oSeparated o Divorced o Widowed
Employer: ______Job Title: ______Length of Employment: ____
Work Address: ______
City: ______State: ______Zip: ______
Other Adults in the Household
Relation to Campers: ______Gender: o Male o Female
First Name: ______Last Name: ______Birth date: _____/_____/_____
Employer: ______Job Title: ______Length of Employment: ____
Work Address: ______
City: ______State: ______Zip: ______
Relation to Campers: ______Gender: o Male o Female
First Name: ______Last Name: ______Birth date: _____/_____/_____
Employer: ______Job Title: ______Length of Employment: ____
Work Address: ______
City: ______State: ______Zip: ______
Monthly Household Income – All Sources
(This section must be completed or your application will be considered incomplete)
Required
o 2016 Federal Taxes included
o 4 current paystubs for all working household members included
Required if applicable
o DSS Budget sheet or Notice of Decision for Food Stamps and/or Public assistance.
o Social Security Award Letter/Disability Statement (SSI/SSD)
o Unemployment Statement
o Rental contract if receiving subsidies
o Child Support Statement
Are you eligible to receive DSS Funding: o Yes o No
o DSS Budget Sheet or Notice of Decision attached
How much can you afford to pay per session/per child (weekly): $______
Monthly Income / Monthly ExpensesGross Wages/Salaries/Tips / $ / Rent/Mortgage / $
Unemployment / $ / Utilities/Phone / $
Social Security Compensation / $ / Food / $
Child Support / $ / Clothing / $
Aid to Dependent Children / $ / Car Payment/Insurance / $
Food Stamps / $ / Alimony / $
Alimony / $ / Child Support / $
Housing Assistance/Section 8 / $ / Medical / $
Retirement/Pension / $ / Other 1 / $
DSS Subsidy / $ / Other 2 / $
Other / $ / Other 3 / $
Total / $ / Total / $
Please share any special circumstances regarding why you would like to be considered for financial assistance.
______
I certify that the above information is true and complete to the best of my knowledge. I understand that no child will receive support for more than two sessions of summer camp programs or five weeks if both parents are working full time and camp is used as daycare. I realize that the YMCA’s financial resources are limited; and therefore, if eligible, I am expected to seek additional funding from other sources such as the Department of Social Services, if eligible.
Signature of Parent/Guardian
______Date______
YMCA OF GREATER ROCHESTER
CAMP Eastside - 2017
APPLICANT REQUIRED
ESSAY
(Attach to Complete Application)
Parent/Guardian: ______
Camper Name: ______
Essay:
A camp experience, please explain how a summer at Camp Eastside will benefit your child: