Camper Name: / Age / Camp(s) Being Applied For:
Parents Information
Parent’s name:
First / Last / MI
Address:
Street address / Apartment / Unit #
City / State / Zip Code
Home Phone #: / () / Cell/Alt # / ()
Email Address:
Marital Status: / Single / Married / Divorced
Employment Information
Place of employment:
Name of employer:
Address:
Street address / Unit #
City / State / Zip Code
Phone number: / ()
Family Information
What is your household income level?:
$0-$15,000 / $15,001-$25,000 / $25,001-$35,000
$35,001-$45,000 / Over $45,001
Number of people in your household:
Please explain your reason for requesting scholarship assistance:
Reference Information
How did you hear about Push The Rock?
Please list two personal references we can contact:
Name: / Email:
Name: / Email:
Date of application:
Select your camp(s)
Camp #1 June 18-22 Coed All Sports
Camp #2June 25-29 Coed All Sports
Camp #3 July 2-6 Boys’ Basketball
Camp #4 July 9-13 Int. Girls’ Volleyball
Camp #5 July 9-13 Adv. Girl’s Volleyball
Camp #6 July 9-13 Coed All Sports
Camp #7 July 16-20 Coed All Sports
Camp #8 July 16-20 Coed All Sports
Camp #9 July 16-20 Coed Soccer
Camp #10 July 16-20 Coed Martial Arts
Camp #11 July 23-27 Kinder Soccer
Camp #12 July 30-Aug 3 Boys’ Basketball
Camp Details
8:30AM-12:00PM Locust Ages 6-12 $85
8:30AM-12:00PM Forks Ages 6-10 $85
8:30AM-11:30AM Bethel Ages 6-10 $85
8:30AM-11:30AM Bethel Ages 9-12 $85
1:00PM-4:00PM Bethel Ages 13-17 $85
8:30AM-12:00PM Lighthouse Ages 6-13 $85
8:30AM-12:00PM Bridgewater Ages 6-9 $85
1:00PM-4:30PM Bridgewater Ages 10-13 $85
8:30AM-2:30PM Bethany Ages 8-14 $85
8:30AM-12:00PM Faith Ages 6-16 $85
8:30AM-10:30AM Bethany Ages 4-5 $60
8:30AM-2:30PM Bethel Ages 12-16 $155
Personal Information:
Camper’s Name:
Address:
City:
State: Zip:
Home Phone: Age: M F
Birthdate:
Grade Completed:
Name of School:
Name of Church:
Medical Conditions/Allergies:
(attach sheet if more space is needed)
Parent/Legal Guardian:
Work Phone:
Cell Phone:
Email:
Emergency Contact:
Phone:
T-Shirt Size:
Youth: S M L
Adult: S M L XL
How did you hear about us?
______
Payment
Check, Cash, or Money Order enclosed for the amount of:
Check this box if turning in payment with this form: