EASTER SEALS NORTHERN OHIO

1929 A East Royalton Rd.

Broadview Hts., Ohio 44147

(440) 838-0990 or (888) 325-8532 or Fax (440) 838-8440

2018APPLICATION FORCAMPERSHIP ASSISTANCE

DATE: ______

APPLICANT’S NAME: ______

FIRSTLAST

APPLICANT ADDRESS: ______

STREET ADDRESSCITY ZIP COUNTY

PHONE: DAY: (____) ______CELL PHONE : ______EMAIL:______

GUARDIAN: _____ Mother _____ Father _____ Self _____ Other: ______

If not self guardian, complete the following information:

GUARDIAN NAME: ______

FIRST LAST

GUARDIAN ADDRESS: ______

STREET ADDRESSCITY ZIP COUNTY

PHONE: DAY: (____) ______CELL PHONE : ______EMAIL:______

APPLICANT DEMOGRAPHICS: (FOR STATISTICAL PURPOSES ONLY)

ETHNICITY (Check all that apply): ___AFRICAN-AMERICAN ___ NATIVE AMERICAN ___ASIAN ___CAUCASIAN ___HISPANIC ___ OTHER

DATE OF BIRTH: _____/_____/_____ GENDER: ___ MALE ___ FEMALE

DISABILITY

(Must divulge to be considered):______

CAMP INFORMATION (PLEASE INCLUDE THE CAMP BROCHURE)

CAMP NAME:______PHONE:( ) ______FAX: ( ) ______

CAMP ADDRESS: ______

NUMBERSTREET

______

CITYSTATE ZIP CODE COUNTY

Has the applicant been accepted to this camp:YES NO

Type of Camp: DAY RESIDENTIAL

Date/session attending:Month______Dates______

Month______Dates______

Total Cost of Camp:$______Amt. Requesting $______

Will you receive additional funding from:

Medicaid WaiverYES NO

Autism ScholarshipYES NO

Will you receive or are you requesting financial assistance from another organization? YES NO

If yes, please list the name of the organization and the amount you have requested:

______

SOURCES OF HOUSEHOLD INCOME:

INCOME SOURCE / APPLICANT / MOTHER / FATHER
Employment (attach 2 most recent pay stubs) / $ /month / $ /month / $ /month
Unemployment / $ /month / $ /month / $ /month
Child Support / $ /month / $ /month / $ /month
Alimony/Spousal Support / $ /month / $ /month / $ /month
Social Security (SSI/SSDI) (attach copy of ltr) / $ /month / $ /month / $ /month
General Assistance / $ /month / $ /month / $ /month
Other / $ /month / $ /month / $ /month
TOTAL FROM ALL SOURCES

TOTAL ANNUAL HOUSEHOLD ADJ. GROSS INCOME AS LISTED ON 1040, 1040A or 1040EZ $ ______

INCLUDE MOST RECENT SIGNED AND DATED FEDERAL INCOME TAX FORM FOR APPLICANT AND PARENTS ALONG WITH 2 MOST RECENT PAY STUBS, UNEMPLOYMENT DOCUMENTATION, SSI DECLARATION LETTER AND ANY OTHER DOCUMENTS TO PROVE CURRENT HOUSEHOLD INCOME.

TOTAL NUMBER IN HOUSEHOLD: ______

PLEASE LIST ANY CURRENT FINANCIAL HARDSHIPS YOU ARE EXPERIENCING THAT SHOULD BE TAKE UNDER CONSIDERATION: ______

______

I CERTIFY THAT THE INFORMATION LISTED ABOVE VERIFIES THE FAMILY INCOME OF THE APPLICANT:

APPLICANT OR GUARDIAN: ______

(PRINT FULL NAME)

______

(APPLICANT/GUARDIAN SIGNATURE) (DATE)

APPLICATION & INCOME DOCUMENTATION MUST BE RECEIVED ON OR BEFORE APRIL 16, 2018 AT:

Easter Seals Northern Ohio

1929A East Royalton Road

Broadview Heights, OH 44147

APPLICATION WILL NOT BE CONSIDERED UNLESS REQUESTED INCOME DOCUMENTATION IS ATTACHED

ONLY APPLICATIONS FROM PERMANENT RESIDENTS OF ASHLAND, ASHTABULA, CARROLL, CRAWFORD, CUYAHOGA, ERIE, FULTON, GEAUGA, HENRY, HOLMES HURON, LAKE, LORAIN, LUCAS, MEDINA, OTTAWA, PORTAGE, RICHLAND, SANDUSKY, SENECA, STARK, SUMMIT, TUSCARAWAS, WAYNE, WILLIAMS, WOOD & WYANDOT, Ohio Counties will be accepted.

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