CAMPERSHIP APPLICATION
(Application for Financial Assistance)
Due:  Monday, May 23, 2005

Please Print

Girl’s Name:

Mailing Address:

Home Phone: Years in Girl Scouting:

Entering Grade:          Entering into:     BR     JR     CAD   SR

Parent/Guardian’s Name: Employed by:

Parent/Guardian’s Name: Employed by:

Family Income___ (Take Home)

Number and age of children for which family is financial responsible:_

Reference - Name of troop leader or another adult who knows the child:

Name: _

Address:

Work Phone: _ Home Phone:

Camps applied for:

Total Cost of Camp:

Fee Family can Pay:

Total Campership Requested:

Has your Daughter attended Camp Jessie Bloom before?  YES NO  How many years?

Have you previously been awarded a campership?     YES     NO

If yes, describe how much, for what camp, and when awarded:_

Are you applying for a Campership given by another source?  YES     NO

If so, from where and how much?_

Camperships are given to families that can establish a need.  Please describe fully all circumstances that affect your family’s financial need. (use additional paper if needed)

________________________________________________________________________
Signature of Parent/Guardian                                    Date