Scholarship Application

Scholarship application Form

Our goal is to provide assistance to those who are prevented, because of financial hardship and the limited resources or absence of a local “home church”, to attend summer camp at Lake Ann Camp. It is our desire that no child miss out on a Lake Ann Camp experience because of financial circumstances. Limited funding is made possible by the generosity of donors and the Red Canoe. Unfortunately, we cannot guarantee that every request will be granted, so please submit your application as soon as possible. Our Scholarships Coordinator will contact you by phone or e-mail once your request has been reviewed.

Camper Name

First

Last

Parent/Guardian Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

in & scholarship

Home Church Name

If you don’t currently attend a church please put “na”

Church City & State

If you don’t currently attend a church please put “na”

Church Phone Number

Please select one of the following

I’ve asked my church to help scholarship my camper(s) and they have agreed to provide financial assistance.
I’ve asked my church to help scholarship my camper(s) and they are unable to provide financial assistance
NA, I do not attend a church

Summer Camp or Retreat

Summer Camp
Retreat

Week & program requested

Example: Week 3 Junior High

Payment you can afford

Yearly income (from all sources)

Number of people in your household

Number of children attending camp

Scholarship amount requested

Please tell us about any extenuating circumstances related to your financial need which will have contributed to your need for a scholarship

Signature

Clear Signature

Date