LOURDES CAMP

CAMPERSHIP APPLICATION

If you wish to be considered for financial assistance, please complete this form and return it with a $25.00 deposit. Any deposit sent will be deducted from the family portion due. The family portion will be determined by the information provided. If you do not receive a campership the deposit will be returned.

NAME OF CAMPER ______

ADDRESS ______

CITY______STATE ______ZIP ______

TELEPHONE ______DATE OF BIRTH ______

MOTHER’S NAME ______WORK # ______

FATHER’S NAME ______WORK # ______

What week would you like to attend (see website for ages)

___Wk. 1(7/1-7/6) ____Wk. 3(7/15-7/20)

____Wk. 7 (8/12-8/17)

.

Camperships are awarded on a lottery system and directly related to the amount of funds available. Camperships must be used during week 1,3 or 7 depending on the age of the camper.

  1. Is your child receiving ADC (Aid to Dependent Children) or Public Assistance? ______

If YES to the above question, please complete the following:

CASE # ______CASE WORKER______

PHONE # ______

  1. Please provide us with any additional information you feel will be helpful to us in processing your application.

______

______

  1. Have you had any camperships for Lourdes in the past; for how many children; number of years etc. ______

If partial Camperships were available, how much of the $440 fee would you be able to pay? ______

  1. Do you receive any of the following? (Circle and give amount)

a. Child Support ______b. Rental Income ______

c. Alimony ______d. other ______

  1. Please circle BOTH your income level in Column A and the size of your family in Column B.

The family income is:The number of family members, adults included:

Column AColumn B

Between $0 - $499

$5,000 – 9,9993

$10,000 – 14,9994

$15,000 – 19,9995

$20,000 – 24,9996

$25,000 – 29,9997 or more

Above $30,000

Gross Family Income (total wages before deductions (taxes, etc). Provide total amounts:

Mother’s Income ______Father’s Income ______(Weekly or Bi-Weekly)

(Please include a copy of your 2017 Federal Income Tax Return)

The Lourdes CampCampership Program is designed to allow children the opportunity to enjoy an educational/recreational experience at camp, who otherwise might not get that chance because of their family’s financial situation. The Campership Program is funded strictly by donations, which allows only a certain number of applications for the summer. When the funds are depleted, the program is over. All applications must be received by April 20, 2018. Camperships are awarded for all or part of one week only. Anyone receiving campership money will not be allowed to attend another week regardless of his or her financial situation.

RETURN COMPLETED APPLICATIONS TO: Lourdes Camp

Campership Committee 1654 W. Onondaga St.

Syracuse, NY 13204