Proposed Summer Program

Name of Program*

Name of Park District or Organization*

Address of Park District or Organization*

Street Address Address Line 2 City State ZIP Code

Is program available in shortened sessions?*

Yes
No

Number of Sessions Requested

Length of Each Session

Cost per Session

Total Cost of Program*

Amount You Can Provide*

Amount of Scholarship Requested*

Have you applied for any other camp scholarships this year?*

Yes
No

Name of Scholarship*

Amount*

Address of Scholarship Group*

Street Address Address Line 2 City State ZIP Code

What will your child do if he/she does not attend this program?*

Financial Data

Annual Income within your household (Include all sources of income such as wages, public aid, child support, and other government assistance). Verification may be requested by the SEDOL Foundation. All information will remain confidential.

Annual Income*

$0 - $15,000
$15,001 - $25,000
$25,001 - $40,000
$40,001 - $50,000
$50,001 - $60,000
Over $60,000

Number of persons in household*

Number of adults in household*

Number of dependents in household*

Ages of dependents in household*

Does your child receive Medicaid or SSI?*

Yes
No

Does your child qualify for free or reduced lunches at school?*

Yes
No

Please describe any extenuating or unusual circumstances (medical bills, excessive financial burdens, etc.)

Student Information

Name of Student*

First Last

Date of Birth*

Phone

Disability*

Name of Parent/Guardian*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Current School

District of Residence

Current Teacher

Current Social Worker / Psychologist (if any)

Did you child qualify for ESY (Extended School Year, also known as summer school) this year?

Yes
No

Applicant Verification

I understand that this application will be kept confidential and will be evaluated to determine whether I qualify for scholarship assistance. I understand that scholarship assistance will be determined by need and availability of SEDOL Foundation Scholarship Program funds. I have answered all of the above questions honestly and completely.

Name of Applicant*

First Last

Relationship to Student*

Email*

Date*

Additional Documents and Files

Drop files here or

Accepted file types: jpg, gif, png, pdf, doc, docx, xls, xlsx, ppt, pptx, Max. file size: 50 MB.

Please upload any additional documents, brochures, and files that will assist in your application.

Camp Scholarship Form

Proposed Summer Program

Financial Data

Student Information

Applicant Verification

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