4âH Camp Wabasso Financial Aid Applicaon
4‐H Camp Wabasso Financial Aid Applica on All information is strictly confidential. Please return to Lori Robinson at: Cornell Cooperative Extension of Jefferson County 203 North Hamilton Street, Watertown, NY 13601
DUE DATE: MAY 1, 2015 A separate application is required for each child. We will send notification to ALL applicants by May 29, 2015.
SECTION 1: CHILD’S INFORMATION Name: ___________________________________________ Age: ______
Gender: □ M
□F
Address: ______________________________________ City: ______________ State: ____ Zip: ______ Number of years attending 4-H Camp Wabasso: _______ Have you ever received a camp scholarship? I would like my child to attend:
□Y
□ Cloverbud
□N
4-H member? How many years? ____
□Y
□N
How much? ____
□ Cloverbud Plus □ Resident Camp □ Day Camp
SECTION 2: PARENT’S INFORMATION Name: ____________________________________________ Telephone Number: __________________ Address: ______________________________________ City: ______________ State: ____ Zip: ______ SECTION 3: FAMILY INFORMATION (Application will not be considered if this section is not filled out.)
□ Deceased □ Not Involved Guardian / Mother / Stepmother □ Unemployed □ Disabled Place of Employment: ___________________________________________ Hours per week: ________ □ Unemployed □ Disabled □ Deceased □ Not Involved Guardian / Father / Stepfather Place of Employment: ___________________________________________ Hours per week: ________ Is either parent/guardian military?
□ Active Duty
□ Retired
□Y
□ Reserves
□N Branch of Service ________________________ □ Deployed □ Disabled □ Deceased
Family/Child receives public assistance (ex. Department of Social Services, Social Security, Veteran's Benefits, Unemployment, etc.) □ Child □ Parent □ Neither Type of assistance: ________________ Family’s gross income from ALL sources, including public assistance is $______________ per (If self-employed or a business owner, use your gross weekly income from all sources minus allowable business expenses; this equals the family’s gross weekly income.)
□ Week □ Month □ Year
Number of people living in household: ____ Number of children living at home: ____ Age(s): ________ Number of children attending 4-H Camp Wabasso: _____
SECTION 5 Please write any additional information that you feel would help our selection committee to better understand the financial aid or special needs of your child. The more information we have, the easier it will be to determine a family’s need for financial aid. This section must be completed or applicants will not be eligible for assistance. _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________
2015 4-H Camp Wabasso Rates Week Cloverbud Cloverbud Plus Traditional Camp Trad. Day Camp Trad. Day Camp Week 7 Day Camp
Age 6-8 6-8 8-16 8-16 8-16 8-16
Early Bird – Early Bird – Full Rate – Full rate – Jefferson County Out of County Jefferson County Out of County $95 $110 $105 $120 $150 $160 $160 $170 $310 $335 $335 $360 $220/week-You provide transportation to and from 4-H Camp Wabasso. $275/week-Transportation from Indian River High School (subject to availability) $300/week-Transportation from Indian River High School (subject to availability)
The following must be filled out in order to be eligible for financial aid. Please note that scholarships are for Week 1 of camp (June 28-July 3). Partial fee we can afford (Suggested minimum payment is $35.00) ________________________ Financial aid request $ ___________________________ Signature: _______________________________________________________ Date: ___________ In order to qualify for financial aid for 4-H Camp Wabasso, you must meet the same criteria as required for a free or reduced school lunch. You must be at or under the income that correlates with your family size in the following table. Size of Family Unit (Including all adults and children)
48 Contiguous States, D.C. and Outlying Jurisdictions
Size of Family Unit (Including all adults and children)
48 Contiguous States, D.C. and Outlying Jurisdictions
1
$21,590
5
$51,634
2
$29,101
6
$59,145
3
$36,612
7
$66,656
4
$44,123
8
$74,167
For family units with more than eight members, add $7,511 for each additional family member.
DUE DATE: MAY 1, 2015 A separate application is required for each child. We will send notification to ALL applicants by May 29, 2015.
SECTION 1: CHILD’S INFORMATION Name: ___________________________________________ Age: ______
Gender: □ M
□F
Address: ______________________________________ City: ______________ State: ____ Zip: ______ Number of years attending 4-H Camp Wabasso: _______ Have you ever received a camp scholarship? I would like my child to attend:
□Y
□ Cloverbud
□N
4-H member? How many years? ____
□Y
□N
How much? ____
□ Cloverbud Plus □ Resident Camp □ Day Camp
SECTION 2: PARENT’S INFORMATION Name: ____________________________________________ Telephone Number: __________________ Address: ______________________________________ City: ______________ State: ____ Zip: ______ SECTION 3: FAMILY INFORMATION (Application will not be considered if this section is not filled out.)
□ Deceased □ Not Involved Guardian / Mother / Stepmother □ Unemployed □ Disabled Place of Employment: ___________________________________________ Hours per week: ________ □ Unemployed □ Disabled □ Deceased □ Not Involved Guardian / Father / Stepfather Place of Employment: ___________________________________________ Hours per week: ________ Is either parent/guardian military?
□ Active Duty
□ Retired
□Y
□ Reserves
□N Branch of Service ________________________ □ Deployed □ Disabled □ Deceased
Family/Child receives public assistance (ex. Department of Social Services, Social Security, Veteran's Benefits, Unemployment, etc.) □ Child □ Parent □ Neither Type of assistance: ________________ Family’s gross income from ALL sources, including public assistance is $______________ per (If self-employed or a business owner, use your gross weekly income from all sources minus allowable business expenses; this equals the family’s gross weekly income.)
□ Week □ Month □ Year
Number of people living in household: ____ Number of children living at home: ____ Age(s): ________ Number of children attending 4-H Camp Wabasso: _____
SECTION 5 Please write any additional information that you feel would help our selection committee to better understand the financial aid or special needs of your child. The more information we have, the easier it will be to determine a family’s need for financial aid. This section must be completed or applicants will not be eligible for assistance. _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________
2015 4-H Camp Wabasso Rates Week Cloverbud Cloverbud Plus Traditional Camp Trad. Day Camp Trad. Day Camp Week 7 Day Camp
Age 6-8 6-8 8-16 8-16 8-16 8-16
Early Bird – Early Bird – Full Rate – Full rate – Jefferson County Out of County Jefferson County Out of County $95 $110 $105 $120 $150 $160 $160 $170 $310 $335 $335 $360 $220/week-You provide transportation to and from 4-H Camp Wabasso. $275/week-Transportation from Indian River High School (subject to availability) $300/week-Transportation from Indian River High School (subject to availability)
The following must be filled out in order to be eligible for financial aid. Please note that scholarships are for Week 1 of camp (June 28-July 3). Partial fee we can afford (Suggested minimum payment is $35.00) ________________________ Financial aid request $ ___________________________ Signature: _______________________________________________________ Date: ___________ In order to qualify for financial aid for 4-H Camp Wabasso, you must meet the same criteria as required for a free or reduced school lunch. You must be at or under the income that correlates with your family size in the following table. Size of Family Unit (Including all adults and children)
48 Contiguous States, D.C. and Outlying Jurisdictions
Size of Family Unit (Including all adults and children)
48 Contiguous States, D.C. and Outlying Jurisdictions
1
$21,590
5
$51,634
2
$29,101
6
$59,145
3
$36,612
7
$66,656
4
$44,123
8
$74,167
For family units with more than eight members, add $7,511 for each additional family member.
