Adirondack Scholarship Foundation, Inc. · 2021 Stipend Application

CAMPER INFORMATION

How many children are applying?

Applicant #1

Name of Child:

*

Age on July 1, 2121:

*

Sex:

Current School:

*

How many summers has your child attended Pok-O-MacCready Camps?

*

Applicant #2

Name of Child:

Age on July 1, 2121:

Sex:

Current School:

How many summers has your child attended Pok-O-MacCready Camps?

*

Applicant #3

Name of Child:

Age on July 1, 2121:

Sex:

Current School: Copy

How many summers has your child attended Pok-O-MacCready Camps?

*

Original (native) speaking language of the child:

*

English

Other

Parent Involvement

*

Which parents will be involved in the application and payment process?

If other, please explain:

*

PARENT INFORMATION

FATHER or MALE GUARDIAN

Name

*

First Name

Last Name

Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Email

*

Verify Email

*

Phone

*

Occupation:

*

Employer:

*

MOTHER or FEMALE GUARDIAN

Name

*

First Name

Last Name

Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Email

*

Verify Email

*

Phone

*

Occupation:

*

Employer:

*

Will both parents be contributing towards tuition?

(for divorced/separated parents)

Yes

No

FINANCIAL INFORMATION

AID REQUEST

2021 Tuition Prices range from $1900 (3-week day camp) to $8400 (full season overnight), and may vary, depending on the session. Knowing the above rates, and the number of children applying for aid,

We are requesting $1,000 for each of our children applying for camp

*

YES!

Our preferred camp session is*

*

* Scholarship may be applied towards any session. Families are fully responsible for the balance of tuition + all expenses

INCOME STATEMENT

All information provided will be kept in strict confidence. The foundation may request an applicant’s tax returns, and should that request be denied, it is understood that this may decrease the applicant’s chances for receiving financial aid.

WAGES, SALARIES, TIPS

*

Father / Male Guardian

WAGES, SALARIES, TIPS

*

Mother / Female Guardian

B. Dividends, Interest, Profit, Alimony/Child Support

OTHER TAXABLE INCOME Copy

TOTAL ANNUAL INCOME

*

Number of household members dependent on the above income:

*

Do you own or rent your home/apartment?

*

Monthly Mortgage:

*

Remaining Balance (principal)

*

What is your monthly rent?

*

Please specify any debts, unexpected or unusual financial circumstances:

SUPPORTING INFORMATION

Please feel free to upload a cover letter, and any supporting financial information that may be of help to our scholarship award committee.

E-SIGNATURE (Your name)

*

I certify that the information reported on this form is, to the best of my knowledge, correct and complete, and understand that the foundation reserves the right to request financial documentation.

Date

*

(mm/dd/yyyy)

Upon hitting the submit button, you will be directed to a page containing additional "CAMPER QUESTIONNAIRE" and "REFERENCE" forms.