CAMP HOLLIS

CAMPER APPLICATION FOR NINE TO FOURTEEN YEAR OLD

SECTION I

Child’s Name ______Nick Name ______

Last First

Address ______Street/Road/Route City Zip

Date of Birth ______/______/______Age ______Sex ______County of Residence ______

School ______Present Grade ______

Name of Mother/Guardian ______Name of Father/Guardian______

Mother/Guardian Home Phone No. ______Father/Guardian Home Phone No.______

Mother/Guardian Work No. ______Father/Guardian Work No. ______

Mother/Guardian Cell Phone No. ______Father/Guardian Cell Phone No. ______

In the event parent/guardian cannot be reached and advice and/or permission is needed, the next responsible adult who is to be contacted locally is (Please provide a different contact person and contact information from information listed above):

Name ______Address ______

Phone No. ______Alternate Phone No. ______Relationship to Camper ______

*I give my permission for my child’s picture to be taken and used for publicity purposes only. ___Yes ___No

*I give my permission for my child to self-administer sunscreen to prevent over exposure to the sun. ___Yes ___No

SECTION II OSWEGO COUNTY RESIDENTS’ FEE DETERMINATION (NON-RESIDENTS PAY $225)

Foster Child: S ______Child Receiving Cash Public Assistance: PA ______

Case No. Case No.

GROSS ANNUAL INCOME ELIGIBILITY GUIDELINES

FEES
(Circle amount you will pay) /

CATEGORY 1

$35 If total household
income is equal to or
less than: /

CATEGORY 2

$65 If total household
income is between: /

CATEGORY 3

$130 If total household
income is between: /
CATEGORY 4
$190 If total household income exceeds Category 3
Number of Persons
In Household / Include income from Child Support, Alimony, SSI, Unemployment, etc.
1 / $15,301 / $15,302 - $21,775 / $21,776- $30,602 / If total
household
income is
more than
amount in
CATEGORY 3
2 / $20,709 / $20,710 - $29,471 / $29,472- $41,418
3 / $26,117 / $26,118 - $37,167 / $37,168 - $52,234
4 / $31,525 / $31,526 - $44,863 / $44,864 - $63,050
5 / $36,933 / $36,934- $52,559 / $52,560 - $73,866
For each additional family member add: / $5,408 / $7,696 / $10,816

à My signature certifies that my total household income is accurate as indicated by the fee amount I am paying: $______.

Please check one: Paid by cash/check _____ Pay by credit card ______

Parent/Guardian Signature ______

CHOOSE A WEEK FOR ATTENDANCE

AGE REQUIREMENTS

Age 9 or 10 by the first day of camp

Age 11or 12 by the first day of camp

Age 13 or 14 by the first day of camp

SECTION III

Indicate your choice(s) for your child to attend by a check mark next to each week desired. We will make every effort to have your child attend for the week(s) you have indicated. Please understand that age groups are set up to provide a happy and safe experience for our campers…no exceptions for age groups can or will be made.

Families experiencing extreme circumstances or difficulties are encouraged to contact our office (315-349-3451) for information regarding financial support beyond the sliding scale.

All registration forms (Camper Application, Medical Form, Immunization Record, USDA Form) must be complete and payment in full or completed scholarship application is required to secure a spot for Camp Hollis.

Completed Registrations are accepted on a first come, first served basis.

o Please check this box if you are applying for a scholarship

BE SURE TO SELECT “AGE-ELIGIBILITY WEEKS” WHEN MAKING CHOICES.

**If you are signing up for multiple weeks of Camp your top 2 preferences will be awarded. Additional weeks will be granted after July 8th pending availability.**

______

9 – 10 Year Olds: July 3- July 8 ______July 17- July 22 ______August 7 – August 12 ______

______

11 – 12 Year Olds: June 26–July 1 ______July 10 – July 15______July 31 – August 5 ______

______

13 – 14 Year Olds: July 24 – July 29 ______

______

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- FOR OFFICE USE ONLY -

Before application can be accepted and the application process is complete please make sure:

Date Application Received ______Date Welcome Packet/Medical Form Sent ______

Medical Form Received: Yes______No______Up-to-Date Immunizations Received: Yes______No______

USDA Form Required: Yes _____No______Completed USDA Form Received: Yes______No______

Photo/Sunscreen Permission Checked: Yes______No______

Alternative Emergency Contact Given: Yes_____ No______

Date DSS Verification Letter Sent ______Date DSS Verification Letter Received ______

Check or Money Order Date ______Amount Paid ______

Check No. ______Money Order No. ______

Friends of Camp Hollis ______