Parent/Guardian Name(s)*

Email*

Phone Number*

Child Name(s), Date of Birth & Age (can list multiple children)*

Number of People in Household*

Does your family live in Section 8 or Public Housing?
YesNo

Adjusted Gross Income from most recent Tax Return*

List all weeks your children are available to attend*

June 28-July 9July 12-23July 26-August 6August 9-20

How much can you contribute per week to cover summer camp fees?

By checking the box below, I certify that the information provided is true and accurate to the best of my
knowledge*
Yes