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JEWISH RESIDENTIAL CAMP SCHOLARSHIP CONFIDENTIAL APPLICATION

Member (Parent) Information

* Member's Name

* Member Birthdate

MM/DD/YYYY

Spouse Name

Spouse Brithdate

* Primary Member Email Address

* Primary Member Phone Number (with area code)

* Primary Phone Number is (choose one)

Member Home Phone
Member Cell Phone
Member Work Phone
Spouse Cell Phone
Spouse Work Phone
Other

If the above answer is Other, please explain below:

Additional Phone Number 1 (with area code)

Additional Phone Number 1 is (choose one)

Member Home Phone
Member Cell Phone
Member Work Phone
Spouse Cell Phone
Spouse Work Phone
Other

If the above answer is Other, please explain below:

Additional Phone Number 2 (with area code)

Additional Phone Number 2 is (choose one)

Member Home Phone
Member Cell Phone
Member Work Phone
Spouse Cell Phone
Spouse Work Phone
Other

If the above answer is Other, please explain below:

* Member Street Address with City, State, and Zipcode

Marital Status

Single
Married
Divorced and Single
Divorced and Remarried
It's complicated,...see below

If your marital status is complicated, please explain:

* Amount of scholarship requesting:

Camper Information

* Camper 1 Full Name

* Camper 1 Age

* Camper 1 Grade

* Name of Camp

* Have you paid a deposit for this camp?

If yes, please type in the deposit amount paid:

* Camp Start Date

* Length of Program

* Total Camp Tuition

* Number of years attending this camp

Camper 2 Full Name (skip this section if you do not have additional campers)

Camper 2 Age

Camper 2 Grade

Name of Camp

Have you paid a deposit for this camp?

If yes, please type in the deposit amount paid:

Camp Start Date

Length of Program

Total Camp Tuition

Number of years attending this camp

Camper 3 Full Name (skip this section if you do not have additional campers)

Camper 3 Age

Camper 3 Grade

Name of Camp

Have you paid a deposit for this camp?

If yes, please type in the deposit amount paid:

Camp Start Date

Length of Program

Total Camp Tuition

Number of years attending this camp

Camper 4 Full Name (skip this section if you do not have additional campers)

Camper 4 Age

Camper 4 Grade

Name of Camp

Have you paid a deposit for this camp?

If yes, please type in the deposit amount paid:

Camp Start Date

Length of Program

Total Camp Tuition

Number of years attending this camp

Member (Parent) Employment Information

* Member Occupation/Position

* Employment Status

* Employer/Company Name

* Employer/Company Street Address, City, State, Zipcode

* Length of Employment

* Business Phone Number

Spouse Occupation/Position

Employment Status

Employer/Company Name

Employer/Company Street Address, City, State, Zipcode

Length of Employment

Business Phone Number

Member (Parent) Income Information

* Member Total Gross Salary and Wages (before taxes and deductions)

* Government Income (Social Security, SSI, SSD)

* Other taxable income (investments, pension, IRAs, rentals, alimony, etc.)

* Non-taxable income (child support, municipal bonds)

Spouse Total Gross Salary and Wages (before taxes and deductions)

Government Income (Social Security, SSI, SSD)

Other taxable income (investments, pension, IRAs, rentals, alimony, etc.)

Non-taxable income (child support, municipal bonds)

* Do you anticipate grants for this trip from other sources?

If Yes, please describe all possible other grant/scholarship sources and amount, if known.

Member Dependent Information

* Dependent 1 Full Name (Please list all dependents including the traveler(s).)

* Birthdate

* Grade Next School Year

* School Name

* Annual Tuition

Dependent 2 Full Name (if you do not have an additional dependent then please skip to the next section)

Birthdate

Grade Next School Year

Annual Tuition

School Name

Dependent 3 Full Name (if you do not have an additional dependent then please skip to the next section)

Birthdate

Grade Next School Year

Annual Tuition

School Name

Dependent 4 Full Name (if you do not have an additional dependent then please skip to the next section)

Birthdate

Grade Next School Year

Annual Tuition

School Name

Please use this area for any additional dependent information:

Summary and Signatures

Please state succinctly the reason(s) you are requesting a camp scholarship. If applicable, please explain: income loss due to unemployment, business reversals or bankruptcy, divorce, etc.; extraordinary expenses as a result of illness, nursing home costs, or legal settlements; and any other matter creating extenuating financial circumstances. It will be helpful if you give us specific facts and figures.

* Summary Statement:

I AFFIRM THAT THE INFORMATION CONTAINED HEREIN IS TRUE AND ACCURATE BY TYPING MY NAME AND DATE BELOW:

* Member, please type your name and date

* Spouse, please type your name and date, or "n/a" if not applicable

ALL SUBMITTED INFORMATION WILL REMAIN STRICTLY CONFIDENTIAL.

Account Details

Enter your name and e-mail address for your confirmation:

*E-mail

*First Name

*Last Name

Payment Information

Account

Credit Card

Name on Card

Card Type

Card Number

Expiration Date

Card Verification Number

Address Line 1

City

State/Province

Zip

Comments

Increase the payment amount by 3% to cover credit card fees (No fee for Checking)

Total:

JEWISH RESIDENTIAL CAMP SCHOLARSHIP CONFIDENTIAL APPLICATION

Member (Parent) Information

Camper Information

Member (Parent) Employment Information

Member (Parent) Income Information

Member Dependent Information

Summary and Signatures

Account Details

Enter your name and e-mail address for your confirmation:

Payment Information

Credit Card

Checking Account

For added Security please check the box below.

JEWISH RESIDENTIAL CAMP SCHOLARSHIP CONFIDENTIAL APPLICATION

Member (Parent) Information

Camper Information

Member (Parent) Employment Information

Member (Parent) Income Information

Member Dependent Information

Summary and Signatures

Account Details

Enter your name and e-mail address for your confirmation:

Payment Information

Credit Card

Checking Account

For added Security please check the box below.

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