Registration Fee Waiver Application (All Camps)

Registration Fee Waiver Application

Before you complete your financial fee waiver application, please make sure you have completed BOTH the youth and adult applications for EACH person who would like to attend camp.

Please only complete ONE (1) application PER FAMILY.

If your family has attended camp two or more times in the past, you are not eligible for the registration fee to be waived.

* Indicates required field

Name of Adult Applicant *

First

Last

Date of Birth (MM/DD/YYYY) *

Name of Child Applicant *

First

Last

Name of 2nd Child Applicant (if applicable) *

First

Last

Name of 3rd Child Applicant (if applicable) *

First

Last

Name of 4th Child Applicant (if applicable) *

First

Last

General Information

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Parent/Guardian Phone Number *

Secondary Phone Number *

Dependent Information

Please list the dependents (not including yourself) living in the household. If none, you may skip this section.

Name of Dependent #1 *

First

Last

Age of Dependent #1 *

Relationship to Dependent #1 *

Name of Dependent #2 *

First

Last

Age of Dependent #2 *

Relationship to Dependent #2 *

Name of Dependent #3 *

First

Last

Age of Dependent #3 *

Relationship to Dependent #3 *

Name of Dependent #4 *

First

Last

Age of Dependent #4 *

Relationship to Dependent #4 *

Name of Dependent #5 *

First

Last

Age of Dependent #5 *

Relationship to Dependent #5 *

Name of Dependent #6 *

First

Last

Age of Dependent #6 *

Relationship to Dependent #6 *

Employment Information

Occupation (if unemployed, please type "unemployed") *

Length of Employment *

Gross Monthly Salary *

Second Occupation (if applicable) *

Length of Employment (w/ Second Occupation - if applicable) *

Gross Monthly Salary (w/ Second Occupation - if applicable) *

Income Information

List TOTAL income PER MONTH

Applicant Gross Salary *

Social Security Benefits (if none, please enter "0") *

Disability Benefits (if none, please enter "0") *

Food Stamps (if none, please enter "0") *

Rental Income (if none, please enter "0") *

Student Loan, Grant, Tuition Reimbursements (if none, please enter "0") *

Unemployment Compensation (if none, please enter "0") *

Applicant's Spouse's Salary (if none, please enter "0") *

Pension (if none, please enter "0") *

State Assistance (if none, please enter "0") *

Alimony/Child Support (if none, please enter "0") *

Business Income (if none, please enter "0") *

Other Income (if none, please enter "0") *

TOTAL MONTHLY INCOME (sum of all listed income above) *

Expenses

List TOTAL expenses PER MONTH

Rent Payment (if none, please enter "0") *

Food (if none, please enter "0") *

Utilities (if none, please enter "0") *

Insurance Premiums (if none, please enter "0") *

Auto Payments (if none, please enter "0") *

Charge Account Payments (ie. credit cards, etc. - if none, please enter "0") *

Loan Payments (ie. mortgages, equity lines, etc. - if none, please enter "0") *

Child Support (if none, please enter "0") *

Child Care (if none, please enter "0") *

Other Expenses (if none, please enter "0") *

TOTAL MONTHLY EXPENSES (sum of all listed expenses above) *

SPECIAL CIRCUMSTANCES: Please list any special circumstances not previously listed that may affect your financial status. *

The Hospice & Palliative Care Foundation does not discriminate on any basis of who is accepted into camp.

Please read and check box below *

I hereby certify that all of the information above is accurate to the best of my knowledge.

Please type your name below to certify this information. *

Note: please make sure that EACH person - child and family member - attending camp has submitted an individual application. For example, if a mother is bringing two of her children, three applications must me submitted - one "Adult Application" for the mother and two "Child Applications" for her children.

Submit Application

*Please make sure you have completed ALL areas of this application. If you DO NOT see a "Completed Application" notification on the page once you click "Submit Application,” please review the application and look for any red boxes and stars, indicating a required field you may have failed to complete.*