Camper Application for Eight Year Old

CAMP HOLLIS

CAMPER APPLICATION FOR EIGHT YEAR OLD

Child’s name: Click here to enter text. Address: Click here to enter text.

Date of birth: Click here to enter a date. Age: Sex: County of Residence: Click here to enter text.

School: Click here to enter text.Present Grade: Click here to enter text.

Name of Mother/Guardian: Click here to enter text. Name of Father/Guardian: Click here to enter text.

Mother/Guardian Home Phone No.: Click here to enter text.Mother/Guardian Cell No: Click here to enter text.

Father/Guardian Home Phone No: Click here to enter text.Father/Guardian Cell No:Click here to enter text.

Mother/Guardian work No: Click here to enter text. Father/Guardian Work No: Click here to enter text.

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: Click here to enter text. Address: Click here to enter text. Phone No: Click here to enter text.

Alternate Phone No.: Click here to enter text. Relationship to camper: Click here to enter text.

• I give my permission for mu child’s picture to be taken and used for publicity purposes only.

______YES______NO

OSWEGO COUNTY RESIDENTS FEE DETERMINATION (NON-RESIDENTS PAY $75)

Foster Child: Case Number: Click here to enter text.Child receiving Public Assistance: Click here to enter text.

GROSS ANNUAL INCOME ELIGIBILITY GUIDELINES

FEES►
(Circle amount you will pay) / Category I
$15 if total household income is equal to or less than: / Category 2
$25 if total household is between: / Category 3
$50 if total household income is between: / Category 4
$65 if total household
income exceeds category 3
Number of persons in household / Include income from child support►►► / Alimony, SSI
►►►►► / Unemployment, etc….
1 / $14,937 / $14,938-$21,257 / $21,258-$29,874 / If total household income is more than amount in category 3
2 / $20,163 / $20,164-$28,694 / $28,695-$40,326
3 / $25,389 / $25,390-$36,131 / $36,132-$50,778
4 / $30,615 / $30,616-$43,568 / $43,568-$61,230
5 / $35,841 / $35,842-$51,005 / $51,006-$71,682
For each additional family member add: / $5,226 / $7,437 / $10,452

My signature certifies that my total household income is accurate and indicated by the fee amount I am paying: Click here to enter text.

Parent/Guardian Signature: Click here to enter text.

Child must be 8 years old by the first day of camp. 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 serve basis.

Will you be applying for a scholarship? ____YES _____NO

-FOR OFFICE USE ONLY-

Before application can be accepted and the application process is complete 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 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:______