Jewish Federation of Greater Harrisburg Andrea Weikert, Program ...
Jewish Federation of Greater Harrisburg Andrea Weikert, Program Director Application for Financial Aid Assistance for Camp All information submitted on or with this application shall remain confidential. Applications must be submitted by February 3, 2014. Call 236-9555, extension 3108 with any questions. Section 1 - Parent Information #1:
Parent
Parent
Name:
_________________________
Address:
_________________________
____________________________ ____________________________
_________________________ Phone:
#2:
____________________________
W: _________________________
____________________________
H: _________________________
____________________________
For purposes of the processing of this application, Parent #1 shall be the prime contact. Marital status of Parents:
___ married
___ divorced
___ separated ___ widowed
Children’s permanent household of residence is: ____ Parent #1
____ Parent #2
Section 2 - Children for whom Scholarship Assistance is Sought Children registering for camp: CHILD #1 Name: _________________________ Camp:
___ Gan
# of weeks: ____
___ Chaverim
M/F
Date of Birth: ____________ Grade: _______
___ Sabra
Regular Fee: ______
___ Maccabee
___ Giborim
First year attending camp? Y
Have you previously received scholarship assistance for camp for this child? Y
N N
CHILD #2 Name: _________________________ Camp:
___ Gan
# of weeks: ____
___ Chaverim
M/F
Date of Birth: ____________ Grade: _______
___ Sabra
Regular Fee: ______
___ Maccabee
___ Giborim
First year attending camp? Y
Have you previously received scholarship assistance for camp for this child? Y
N N
CHILD #3 Name: _________________________ Camp:
___ Gan
# of weeks: ____
___ Chaverim
M/F
Date of Birth: ____________ Grade: _______
___ Sabra
Regular Fee: ______
___ Maccabee
___ Giborim
First year attending camp? Y
Have you previously received scholarship assistance for camp for this child? Y
N N
Section 3 - Household information Please list all permanent residents of the primary parent’s household: Name
Age
M/F
Relationship
1.
____________________
____
____
_______________
2.
____________________
____
____
_______________
3.
____________________
____
____
_______________
4.
____________________
____
____
_______________
5.
____________________
____
____
_______________
6.
____________________
____
____
_______________
7.
____________________
____
____
_______________
8.
____________________
____
____
_______________
9.
____________________
____
____
_______________
Section 4 - Earnings Information Please identify annual income for the following individuals: Parent
#1
Parent #2
Other #1*
Other #2*
Wages/Tips
__________
___________
___________
___________
Business Income
__________
___________
___________
___________
Interest/ Dividends
__________
___________
___________
___________
Unemployment/ Disability __________
___________
___________
___________
Other:
__________
___________
___________
___________
Total:
__________
___________
___________
___________
* Income shall be reported for all persons age 21 or over residing in the household.
Section 5 - Expenditure Information Please list total estimated average monthly expenses for your househould for the following items: Rent Mortgage Payment Food Clothing Medical Expenses Heating (Oil, Gas, Coal, etc) Electricity Telephone Cable TV Water Sewer Trash Removal Other Utilities: Home Repair/Maintenance Education Gifts Recreation Car/Gas Transportation (bus, etc) Insurance - Real Estate Insurance – Auto Insurance - Health/Life Taxes - Real estate Taxes – Income Taxes - Social Security Taxes - Personal Property Union/Professional Dues Child Care Child Support Planned major purchases Financing Costs Moving Expenses Car/Truck Payment #1 Car/Truck Payment #2 Federal Debts/Student Loans Credit Card Payments TOTAL MONTHLY HOUSEHOLD EXPENSES
Section 6 - Explanation of Extreme Circumstances Please attach a separate letter to indicate any extreme circumstances, either temporary or permanent, that you feel should be taken into consideration in the determination of the amount of scholarship to be provided. Circumstances that will receive consideration will include, but not be limited to, health problems or loss of employment. Voluntary change of employment shall not be acceptable to receive consideration for additonal scholarship. ____
I have attached a letter explaining extreme circumstances.
____
I have not attached a letter explaing extreme circumstances. Section 7 - Attachments
The following attachments must be provided as documentation to accompany this application: ____
All W-2 forms for applicable household members for the last tax year.
____
All 1099 forms for applicable household members for the last tax year.
____
Copy of most recent pay stub for applicable household members. Section 8 - Certification
I certify that the information provided herein is genuine and represents the complete and correct answers to the questions provided. I understand that the balance of camp tuition not covered by scholarship must be paid in its entirety or my child will be denied admittance into the JCC camp program. ____________________________________ Parent #1 Signature ************************************************************************************************************************ * For Office Use Only FIS Test: ____ VLI ____LI ____MI ____NA I/E Test: _____ EC Test: Y N Regular
Scholarship
Balance
Child 1
______
_________
________
Child 2
______
_________
________
Child 3
______
_________
________
Approved by: _________________________________ Date: _________________________
Parent
Parent
Name:
_________________________
Address:
_________________________
____________________________ ____________________________
_________________________ Phone:
#2:
____________________________
W: _________________________
____________________________
H: _________________________
____________________________
For purposes of the processing of this application, Parent #1 shall be the prime contact. Marital status of Parents:
___ married
___ divorced
___ separated ___ widowed
Children’s permanent household of residence is: ____ Parent #1
____ Parent #2
Section 2 - Children for whom Scholarship Assistance is Sought Children registering for camp: CHILD #1 Name: _________________________ Camp:
___ Gan
# of weeks: ____
___ Chaverim
M/F
Date of Birth: ____________ Grade: _______
___ Sabra
Regular Fee: ______
___ Maccabee
___ Giborim
First year attending camp? Y
Have you previously received scholarship assistance for camp for this child? Y
N N
CHILD #2 Name: _________________________ Camp:
___ Gan
# of weeks: ____
___ Chaverim
M/F
Date of Birth: ____________ Grade: _______
___ Sabra
Regular Fee: ______
___ Maccabee
___ Giborim
First year attending camp? Y
Have you previously received scholarship assistance for camp for this child? Y
N N
CHILD #3 Name: _________________________ Camp:
___ Gan
# of weeks: ____
___ Chaverim
M/F
Date of Birth: ____________ Grade: _______
___ Sabra
Regular Fee: ______
___ Maccabee
___ Giborim
First year attending camp? Y
Have you previously received scholarship assistance for camp for this child? Y
N N
Section 3 - Household information Please list all permanent residents of the primary parent’s household: Name
Age
M/F
Relationship
1.
____________________
____
____
_______________
2.
____________________
____
____
_______________
3.
____________________
____
____
_______________
4.
____________________
____
____
_______________
5.
____________________
____
____
_______________
6.
____________________
____
____
_______________
7.
____________________
____
____
_______________
8.
____________________
____
____
_______________
9.
____________________
____
____
_______________
Section 4 - Earnings Information Please identify annual income for the following individuals: Parent
#1
Parent #2
Other #1*
Other #2*
Wages/Tips
__________
___________
___________
___________
Business Income
__________
___________
___________
___________
Interest/ Dividends
__________
___________
___________
___________
Unemployment/ Disability __________
___________
___________
___________
Other:
__________
___________
___________
___________
Total:
__________
___________
___________
___________
* Income shall be reported for all persons age 21 or over residing in the household.
Section 5 - Expenditure Information Please list total estimated average monthly expenses for your househould for the following items: Rent Mortgage Payment Food Clothing Medical Expenses Heating (Oil, Gas, Coal, etc) Electricity Telephone Cable TV Water Sewer Trash Removal Other Utilities: Home Repair/Maintenance Education Gifts Recreation Car/Gas Transportation (bus, etc) Insurance - Real Estate Insurance – Auto Insurance - Health/Life Taxes - Real estate Taxes – Income Taxes - Social Security Taxes - Personal Property Union/Professional Dues Child Care Child Support Planned major purchases Financing Costs Moving Expenses Car/Truck Payment #1 Car/Truck Payment #2 Federal Debts/Student Loans Credit Card Payments TOTAL MONTHLY HOUSEHOLD EXPENSES
Section 6 - Explanation of Extreme Circumstances Please attach a separate letter to indicate any extreme circumstances, either temporary or permanent, that you feel should be taken into consideration in the determination of the amount of scholarship to be provided. Circumstances that will receive consideration will include, but not be limited to, health problems or loss of employment. Voluntary change of employment shall not be acceptable to receive consideration for additonal scholarship. ____
I have attached a letter explaining extreme circumstances.
____
I have not attached a letter explaing extreme circumstances. Section 7 - Attachments
The following attachments must be provided as documentation to accompany this application: ____
All W-2 forms for applicable household members for the last tax year.
____
All 1099 forms for applicable household members for the last tax year.
____
Copy of most recent pay stub for applicable household members. Section 8 - Certification
I certify that the information provided herein is genuine and represents the complete and correct answers to the questions provided. I understand that the balance of camp tuition not covered by scholarship must be paid in its entirety or my child will be denied admittance into the JCC camp program. ____________________________________ Parent #1 Signature ************************************************************************************************************************ * For Office Use Only FIS Test: ____ VLI ____LI ____MI ____NA I/E Test: _____ EC Test: Y N Regular
Scholarship
Balance
Child 1
______
_________
________
Child 2
______
_________
________
Child 3
______
_________
________
Approved by: _________________________________ Date: _________________________
