2018 SUMMER DAY CAMP Registration Packet

ComejoinusasweentertheLandofOzforsomeSummertimefun.Wewilltravelthe anddiscoverour

“Passions, Dreams and Goals…Oh, My!”and new this year…our Camp Navigate (computer)Coding Program!

Returnyourcompletedformsinoneofthefollowingways: MailtoCamp Navigate,P.O.Box3687,TerreHaute,IN.47803DropoffatTheLifeCenter,3000CollegeAve,TerreHaute,47803,Monday-Friday,4:00p.m.to6:00p.m.

(Pleaseenterthesoutheastdoorbytheramp)

Welcome!ThankyouforchoosingCamp Navigate!Wehaveincludedabriefoverviewofourmissionandpurposetointroduceourselves.Weareexcitedforthearrivalofsummerandarelookingforwardtomeetingyouandyourchild!Oursummerwillbefullofadventureandfunaswelearnaboutleadership,teamwork,howtobeabetterstudentandfutureemployee!Therewillbeswimming,games(somethatyourchildwillinvent),healthymealsandsnacks(maybeevensomefromyourchild’sgarden),diningoutandplentyoffieldtrips,too!Whoarewe?Wearecomprisedofamanagementstaffwithover50yearsofcombinedyouthexperiencewhohavejoinedforceswithavolunteercommitteeofsomeofthecommunity’smostsuccessfulandcommittededucatorsandbusinessmen/womentodevelopaSummer Day Camp with a Purpose! CAMP NAVIGATEMISSIONSTATEMENT ConnectingStudentswithEmployabilitySkillsandTraditionalValuestoensuretheirSuccessfulFutures. Camp Navigatewillofferahighqualityandengagingsummercampforchildrenpre-Kto8thgrade.Wearefocusedondevelopingemployability/softskills,promotinghealthyhabits,andcreatingservant-leaders.Ourcurriculumhasbeenshapedaroundresearchconductednationallyandatthestatelevel,whichshowsthatsoftskilltrainingneedstobedonenotjustwithintheadultworkforce,butalsoduringearlieryears.ThevisionofCamp NavigateisthatallyoungpeopleintheWabashValleyhaveaccesstothisopportunitytoapplytheiracademicskillsandacquirenewcompetenciesthattheirfutureemployerswilldesire,whilesupportingtheiryear-roundlearningandwell-being.DATESANDHOURSJune4ththroughAugust3rd,MondaythroughFriday,7:00amto5:30pm.LOCATIONTheLifeCenter,3000CollegeAve.,TerreHaute REGISTRATION AdditionalregistrationformsarealsoavailableatBaesler’sMarket,OpenDoorBookstore,VigoCountyLibrary(MainBranch),andTheLifeCenterat3000CollegeAve.,TerreHaute.Visitusatwww.campnavigate.organdonFacebook. CONTACTINFOForanyadditionalquestionspleasecontactusatanytime.Youmayreachusbyphoneat812-229-3214or812-201-4862oremailusatinfo@campnavigate.org.

GotoourFacebookpageatCamp Navigateforuptodateinformation.

Camp Navigate’s Three Focus Areas

EmployabilitySkillsWorkforceleadershavelongbeendescribingagapincompetenciesamongrecentgraduatesrevolvingaroundsoftskills,otherwiseknownasemployabilityskills.Thesedesirablequalitiesapplyacrossavarietyofjobsandlifesituationsandarecrucialinpreparationforcollegeandcareersuccess.Moreoftenthannot,theyaredevelopedatanearlyageinlife.

Camp Navigateoffersanopportunityforyoungpeopletodevelop,notonlyemployabilityskills,butalsodesirablelifeskillsthroughsocialization,bylearningthevalues,attitudes,andactionsofothers,whilealsobuildingrelationshipswiththem.Wearecommittedtohelpingyoungpeopledeveloptheabilitytoeffectivelycommunicateandtothinkcriticallyandcreativelywhilecollaboratingwithothers.Ourcamperswillalsoenjoyfunactivitiesthatwillencouragesuchemployabilityskillsasentrepreneurship,projectmanagement,andhowtohandleemotionalsetbacks,whichwillinturnhelpthemtolatertransitionsuccessfullyfromtheearlyyearsoflearningtohighschoolthencollegeoracareer.

HealthyHabitsSure,eatingwellcanbechallenging—familyschedulesarehecticandconvenient;pre-packagedfoodisoftenmoreappealing.ButatCamp Navigate,wereinforcehealthyhabitsinthehopesthatyourchildwilldeveloptheabilitytomakehealthychoicesfortherestofhisorherlifeandthroughouthisorhercareer.Maintaininghealthyhabitsenablesonetoleadalifewithlessstressandapositiveattitude–whichisbeneficialpersonallyandprofessionally.Employeeswhoknowhowtosetfitnessgoalsandstaymotivatedtoexercisearetypicallygoal-orientedandfocusedindividuals.Additionally,healthyandfitemployeesalsotendtohavehigherlevelsofself-confidenceandaremorelikelytoinspireconfidenceinothersaroundthem.

Servant-LeadershipServant-leadersdisplayagenuinedesiretoserveothersforthecommongoodandcollectivehumandevelopment.Camp NavigatebelievesinofferingleadershiptrainingwithChristianprinciples,becausewebelievethisapproachtoleadershipispowerfulandimpactful.Aservant-leaderchoosestoserveothers,regardlessofseniority,race,ethnicity,socioeconomicstatusorfaith.Asaresult,servant-leadershavethecapacitytotransformandeffectivelybringaboutchangewithinnotjustindividualfollowers,butalsowithinentireorganizations.

The Leadership Team

EleanorRamseier–CampNavigateDirectorEleanorhasbeenservingyouthintheWabashValleyfor25+years.Shebeganvolunteeringasayouthworkeralongsideherhusbandin1990.Inthemostrecentpast,asExecutiveDirectorofthelocalYMCA,shehelpeddevelopandoverseetheyouthactivitiesaswellasthesummercamps.Sheisthemotherofthreeawesomeadultchildren.Shehasalwayshadadesiretoencourageyouthtofindtheirpassion,setgoalsandbestrongintheirfaith!WithCampNavigateshecannowcombinethesepassionswithanotheraspirationshehas–developingyouthtosucceedinourcommunity’sworkforce!Shelovesspendingtimewithfamilyandfriends,running,hiking,andanythingadventurous.WhatexcitesyoumostaboutCampNavigate?“ThatthiscommunityhasoverwhelminglyembracedthephilosophyofCampNavigate!Alsothatwe

willhelpdrawattentionforotherstoseetheimportanceofinstillingEmployability SkillsandTraditionalValues intothelivesofourmostimportantasset–ourchildren!”

TimRamseier–DirectorofMiddleSchoolCampersTimhasbeeninvolvedinyouthworksincetheearly80’s.HestudiedinGermany,England,UniversityofWisconsinatMadison,TrinityEvangelicalDivinitySchoolinChicago,andGordon-ConwellSeminaryinBoston.TimiscurrentlytheExecutiveDirectorofYouthforChristandispassionateaboutworkingwithyouth.HeworkswithhundredsofMiddleSchoolandHighSchoolstudentseachmonthduringtheschoolyear.HeismarriedtoEleanorandisalwayslookingforopportunitiestohangoutwithher,theirthreechildren,andtheirgrandchildren!WhatexcitesyoumostaboutCampNavigate?“Theabilitytoshapelives,notjustduringtheschoolyear,butallsummerlongaswepreparethemforthefuture."

BrittanyBahr–DirectorofOperationsWorkingwithchildrenhasplayedahugeroleinhercareerpath.AsayoungteenagersheparticipatedinUnionHospitalVolunTeenProgramvolunteeringforfouryearsattheUnionHospitalChildDevelopmentCenter.Atsixteen,shebeganworkingattheWestVigoCommunityCenterasDirectoroftheAfterSchoolandSummerCampProgramsforthreeyears.Whileinschool,shecompletedseveralearlychildhoodandelementary/specialeducationcoursesgainingalotofknowledgeandinclassroomexperiences.In2013,shewasemployedatalocalYwhereshesupervisedboththeChildWatchandTweenPrograms.In2014,shemadethedecisiontomovetoWilmington,NC,whereshehasbeenemployedasanAssistantDirectoratSoutheastern

PreschoolEducationalCenter.Shecontinuestocompletetrainingsandkeepuptodateoncertificationsandqualificationsinordertobethebestexampleshecanbeforthechildrensheisfortunateenoughtomeet.WhatexcitesyouaboutCampNavigate?‘Helpingyouthdevelopinallaspectsoftheirlifesothattheymaybecomesuccessfuladultsisnotonlymycareergoal,butmypassion–CampNavigatewillgivemethegreatestopportunitytodojustthat!Iaspiretobeapositiveinfluenceandmentorforthosewhowillhavetheabilitytochangetheworld–ourchildren!’

Weekly Themes

Join Camp Navigate during our 2018 Summer Camp as together we journey down the Yellow Brick Road to the Wonderful Land of OZ! At Camp Navigate we will further develop your children’s heart for others, their brains to create and critically think, and the courage to make things happen in their lives! We will enhance your child’s skills of leadership, teamwork, and accountability as we travel the yellow brick road together! Our 9 different weekly themes will focus on some of the most-in-demand Employability (Soft) Skills needed for your child’s future success! We will also enhance academic skills, computer and coding skills (thank you Wabash Valley Community Foundation), S.T.E.A.M., financial literacy, and the new 4 C’s of Communication, Collaboration, Creativity and Critical thinking. AND we will be offering exciting field trips, weekly swimming, guest speakers, and just good, ole, summertime fun! Not only do we hope to prepare your child for the FUTURE, but our hope is for them to realize how amazing they are TODAY!

We will do all of this as we help them realize they were wonderfully created for a purpose!!! Come join us this summer as we find your child’s Passions, Dreams and Goals...Oh, My!

WeekOne:FollowourYellowBrickRoad(goalsetting,developingavision)Thefirstweekwewilldiscusstheimportanceofshort-termandlong-termgoals,howtoobtainthemandhowtohavefunalongtheway!WeekTwo:It’sWhoYouMeetAlongtheWay(embracingdifferences,teamwork,criticalthinking,collaboration)ThisweekisdesignedforthecamperstocelebratetheirdifferencesaswebeginthisjourneyalongourYellowBrickRoadtogether!Dorothy,theTinMan,theScarecrow,andtheLionallcamefromdifferentbackgrounds,yettheysharedacommongoal,supportedeachotherandbecameanamazingteam.

WeekThree:IfIOnlyHadaBrain(innovation,criticalthinking,problemsolving)WewilllearnhowtheScarecrowwhodidn’tthinkhehadabrain,wasthemostinnovativeproblemsolverofall!Wewilldiscoverourgiftsandtalentsandhowtheycanalwaysbeused.

WeekFour:ACheerfulHeart(servantleadership,volunteerism)TheTinManlongedforaheartanddiscoveredhehadonewhenhehelpedothers!Thisweekwewilllearnaboutcompassionandhowtouseourheartstoserveourcommunity.

WeekFive:BetheLion(patriotism,grit,thecouragetofollowyourdreams)Wewillbehonoringtheheroesofourcountryandofourcommunity.Wewillalsolearnwhatitmeanstobearealheroandhoweachofuscanbecomeheroesinourownways…itjusttakescourage!!

WeekSix:YouAlwaysHadthePower,MyDear(leadership,determination,powerofapositiveattitude)ThisweekwewillfocusonDorothy’sabilitytoleadothersandhowherleadershipandcompassionforherteamencouragedthemtocompletetheirjourney!Wewilldiscussothergreatleadersandinnovators,femaleandmale,whowerebigdreamers,struggledattimes,yetperseveredtotheend.

WeekSeven:CountonYOU(accountability,decisionmaking)Thisweekwewilltalkabouthowourchoiceswillinfluenceourfuture.Wewilllearnthatthereisn’talwaysa“manbehindthecurtain”togiveuswhatwedesireinlife.Andwhilelifeisfullofgreatandnot-so-greatevents,weareultimatelyresponsiblefortheroadwechoose.

WeekEight:SomewhereOvertheRainbow(creativity,buildingconfidence)Thereisadreamer,anartist,andaperformerdeepinsideallofus!Wewillcreate,doskits,andlearnhowtoexpressourselvesthroughartisticandcreativeoutlets.Wemayevencreateourownpairofspecialslippers.

WeekNine:There’sNoPlacelikeHome(communication,writingskills)Atsomepointinourliveswewillbeaskedtogiveapublicspeech.Thisweekwewillwriteashortspeechreflectingoursummercamphighlightsandalltheadventuresweexperiencedrighthereinourowncommunity.Wewillthenpresentthattofellowcampers.OurcommunityandIndianaisagreatplacetoliveandwehopeouryouthwillalwaysconsidertheWabashValleytheirhome!

Camp Navigate Rate Sheet

Classification Rate

FullTimeCamper $105.00perweek

Monday–Friday 7:00a.m.–5:30p.m

DiscountOpportunities(discountscannotbecombined)

MultipleSiblings 15%

eachadditionalcamperafterthe1statfullprice.

example: FT$105for1stchild,15%offnextchildren,$90.00ea.

Military 15%

15%discountonallchildren.

example: FT$90.00forallchildren.

FosterChildrenSubsidy(limitedfundsavailable) 50%

Familieswhoarefosteringchildrenareeligibletoreceive50%offperchildlivingintheirhome.

FinancialAssistanceopportunitiesareavailableLimitedfundsareavailableforthosewhofinanciallyqualifythroughourCaulderHuffJohnsonScholarship

FundandFosterFamilySupportFund.Ifyouareinterested,pleasefilloutthescholarshipapplicationand

attachittoyourregistrationformtoseeifyouqualifyfora50%or75%reductioninweeklyfees.

Camp Navigate2018Registration

June4THtoAugust3rd,Monday–Friday7:00amto5:30pmTheLifeCenter,3000CollegeAve.,TerreHaute,IN

RATESHEET/DISCOUNTS/FINANCIALASSISTANCEINFORMATIONATTACHED

TotalRegistrationFees:1stCamperName:

WEEK THEMES YES No June4-8 FollowOurYellowBrickRoad June11-15 It’sWhoYouMeetAlongTheWay June18-22 IfIOnlyHadABrain June25-29 ACheerfulHeart July2-6 BetheLion July9-13 YouAlwaysHadthePower,MyDear July16-20 CountonYOU! July23-27 SomewhereOvertheRainbow July30-Aug3 ThereisNoPlaceLikeHome 2ndCamperName:

WEEK THEMES YES No June4-8 FollowOurYellowBrickRoad June11-15 It’sWhoYouMeetAlongTheWay June18-22 IfIOnlyHadABrain June25-29 ACheerfulHeart July2-6 BetheLion July9-13 YouAlwaysHadthePower,MyDear July16-20 CountonYOU! July23-27 SomewhereOvertheRainbow July30-Aug3 ThereisNoPlaceLikeHome

DISCOUNTS:SiblingDiscountMilitaryDiscountFosterCareSubsidyCorporateSubsidyCaulderHuffJohnsonScholarshipApplicant

RegistrationFeeis$35perchild/$70perhouseholdandistobeaccompaniedwithyourregistrationform.TheWeeklyfeeis$105.00percamper.Chooseyourweeks!Choose1orChoosethemall!

AllchargesincludingRegistrationFeeswillbewithdrawnonmybehalfinthefollowingmanner.

IamauthorizingabankdraftfrommycheckingaccountandIhaveattachedavoidedcheckIamauthorizingacreditcarddraftandIhaveprovidedalltheinformationbelowCreditCardtype:VisaMasterCardCSC:______(backofcard)NameonCard:AuthorizedSignature:CardNumber:ExpirationDate:BillingAddress:BillingZipCode:

Ihavethelegalauthoritytoregisterthechild/childrennamedonthisformandtothebestofmyknowledgetheinformationonthisapplicationformiscompleteandaccurate.Iunderstandthatmyapplicationwillnotbeprocessedunlessitincludesthefullfeeorautomaticdraftauthorization.IntheeventIcannotbereachedinanemergency,Iherebygivepermissiontothedirectoroftheprogramortheirdesigneetosecureemergencymedicalservices,includingtransportationandmedicalcare.Ialsogivepermissionfortheattendingphysiciantoorderinjections,anesthesiaorsurgeryforthischildasnamedabove.Iunderstandthatmedicalandaccidentinsuranceistheresponsibilityoftheparentorguardian.IunderstandthatImayrevokethisreleasebywrittenrequestpresentedwitha48hourpriornotice.

Mychild(ren)maybephotographedand/orinterviewedforCamp Navigatepromotionalpurposes.YESNOThisincludesanypromotionalpurposesusedonsocialmedia.SignatureofParent/Guardian: Date:

_______________________________________________________ _______________________________

Camp NavigateSummerDayCamp2018Registrationv Pleasedropoffthecompletedregistrationformandtheregistrationfeeto:

TheLifeCenter,3000CollegeAve.TerreHaute,between4-6p.m.PleaseusetheSoutheastdoorbytherampv Oryoucanmailto:Camp Navigate,P.O.Box3687TerreHaute,IN,47803.v YouMUSTprovideacopyofchild’simmunizationrecordandarecentphoto.v BesuretofillALLpagesoftheregistrationform

Forassistance,call812-229-3214oremailatinfo@campnavigate.orgv Foradditionalregistrationformsyoumaygotowww.campnavigate.org

CAMPER(mustbesiblingsorfosteredchildtoregisteronthesameregistration)FirstName:MiddleInitial:LastName:

DateofBirth://Gender:Age:GradeinFall2017:ShirtSize:YS/YM/YL/S/M/L/XL

Race:AfricanAmericanAsianAmericanIndianWhiteMulti-RacialNativeHawaiian/PacificIslanderOther

PhysicalConditions/SpecialNeeds:Medications/allergies:

Tobetterserveyourchild,pleaseindicatedifhe/shehasbeendiagnosedwithanyofthefollowing:ADD/ADHDConvulsionBleeding/ClottingDisordersAutismAsperger’sFragileXCerebralPalsyBipolarDis.TouretteRettSyndromeDownSyndromeChronicHealthProblemsAsthma/SevereAllergiesDiabetesHeartdefect/diseaseOther____________________________DoesthischildhaveanIEP(IndividualEducationPlan)YesNoFirstName:MiddleInitial:LastName:

DateofBirth://Gender:Age:GradeinFall2017:ShirtSize:YS/YM/YL/S/M/L/XL

Race:AfricanAmericanAsianAmericanIndianWhiteMulti-RacialNativeHawaiian/PacificIslanderOther

PhysicalConditions/SpecialNeeds:Medications/allergies:

Tobetterserveyourchild,pleaseindicatedifhe/shehasbeendiagnosedwithanyofthefollowing:ADD/ADHDConvulsionBleeding/ClottingDisordersAutismAsperger’sFragileXCerebralPalsyBipolarDis.TouretteRettSyndromeDownSyndromeChronicHealthProblemsAsthma/SevereAllergiesDiabetesHeartdefect/diseaseOtherDoesthischildhaveanIEP(IndividualEducationPlan)YesNo

PARENT/GUARDIANName:RelationshiptoChild:

Address:City:State:Zip:DateofBirth://

1st

2nd

1st

Employer:Wouldyouliketooptinfortextmessagealerts:

Phone(work):Phone(cell):

Email:

Name:RelationshiptoChild:

Address:City:State:Zip:DateofBirth://

Employer:Phone(work)(cell):

Email:

EmergencyContact/AuthorizedPick-Up(anyonepickingupyourchildmustbe:atleast18+andmustshowphotoID)Inadditiontotheparents/guardianslistedabove,Iauthorizethefollowingtopickupthechild(ren)andorbecontactedinanemergency:Name:RelationshiptoChild:Phone(work):Cell:

Name:RelationshiptoChild:Phone(work):Cell:Physician/InsuranceInformation:InsuranceCarrier:PolicyNumber:PhysicianName:Phone:PreferredHospitalintheeventchildneedstotransportedformedicalattention:

Swimming Ability

Please check the swimming ability of your child: ____Non- Swimmer: not able to swim 50 continuous feet without dog-paddling or interrupting a stroke to stand in the water, or both. ____Beginner: able to jump feet-first into water deeper than camper is tall, level off, and begin swimming. Capable of swimming 50 continuous feet, including a sharp turn to return to the starting place. ____Swimmer: able to jump feet first into water deeper than camper is tall, level off, and begin swimming. Capable of swimming 100 yards in a strong manner using more than one stroke. Must be able to float.

PARENT AUTHORIZATION AND RELEASE My child has the medical approval to participate in the activities of CAMP NAVIGATE, and in my judgment my child is in good health and physical condition and able to safely participate in the activities of CAMP NAVIGATE. My child has my permission to engage in all activities offered by CAMP NAVIGATE except as noted by me in writing. I further understand that neither CAMP NAVIGATE nor any of its paid staff or volunteer workers can be held responsible in the event of an accident. I promise and agree on behalf of myself, my spouse or partner, or other family members not to sue and agree to waive, release, discharge, and hold harmless and indemnify CAMP NAVIGATE, its agents, employees, members, and volunteers from all claims, demands, rights, and causes of action of any kind, whether arising from my own acts, the acts of my child, or those of CAMP NAVIGATE. I hereby waive all claims of injury or damage, suffered by my child, myself, my spouse, my partner, or other family member in connection with or arising out of the participation of my child in CAMP NAVIGATE’S activities. I certify that my child is amenable to discipline and free from habits or attitudes which would make him/her an undesirable participant.

CAMP ACTIVITY AND TRANSPORTATION AUTHORIZATION I hereby give permission for my child to participate in camp activities and to travel by bus with the CAMP NAVIGATE staff. I understand that only licensed and qualified personnel will operate any vehicle during Day Camp, and that there will be at least one CAMP NAVIGATE staff member present at all times. I agree to release CAMP NAVIGATE, and its officers, directors, and CAMP NAVIGATE’S staff from any and all claims of damages or liabilities which may arise as a result of my child’s participation in camp activities and bus trips.

EMERGENCY AUTHORIZATION I hereby give permission to the medical personnel selected by CAMP NAVIGATE’S camp director or designated CAMP NAVIGATE staff to order X-rays, routine tests and treatment for me or my child, and, in the event that I am not able to communicate or cannot be reached in an emergency, I hereby give permission to the physician selected by the camp director or designated CAMP NAVIGATE staff to hospitalize, secure proper treatment for, and order injection(s) and/or anesthesia and/or surgery for me or my child

2nd

as named prior. I will be fully responsible for any costs of such treatment, even if not covered by my insurance.

PARENT OR GUARDIAN PERMISSION My signature below indicates that I have the legal authority to sign up the child named on this form and that to the best of my knowledge the information on this application form is complete and accurate. I further understand that this application and the named child’s participation is contingent upon space being available in the program in which I want the child to participate. I also understand that once my registration is confirmed, I must complete payment(s) by the deadlines of said program as outlined prior and that, furthermore, all necessary health, security, and waiver forms must be signed and on file with CAMP NAVIGATE prior to my child attending the program.

_________________________________________________ __________________________ Signature of Parent or Legal Guardian Date

Camp Navigate’s

CaulderHuffJohnsonScholarshipApplicationForm

CaulderHuffJohnsonwasonlytwoyearsoldwhenhetragicallyandaccidentallylosthislifeonJanuary2,2017.Hismother,HeatherKumpfJohnsongrewupinTerreHaute,andalongwithCaulder'sfather,Patrick,they,fromthetimeCaulderwasbornprayeddailythathewouldsomedayglorifyGod.WithgreatfaithandtrusthisparentsknowthatevennowGodisincontrolandthroughCamp Navigates'sScholarshipFundCaulder'slifeisdoingjustthat.TheywouldalsolikeotherstoknowthatjustlikeacompasscanalwaysfinddueNorth,thatGodwillneverchange.Nomatterwhatdirectionyourlifetakes,Heisconstant.LifeislivedbestwhenwetrustandallowGodtonavigateourpath(Proverbs3:5-6).Itcansometimesbeabumpypath,butitisALWAYSthebestone.WehopethattheCaulderHuffJohnsonScholarshipFundwillbeahelptoyourchildashe/shebeginstochoosetheirpathinlife.

REQUIREDDOCUMENTATIONCHECKLIST:

Ø Completedapplication.(Pleaseprintclearlyandfilloutthefrontandbackoftheapplicationcompletely.)Ø Acopyofthefirstpageofthemostrecent1040TaxFormforEACHADULT(age18+)inthehousehold.Ifyoudo

notfiletaxes,youmayobtainanIRStranscriptbycallingtheInternalRevenueServiceat1-800-829-1040orgotowww.irs.gov.

Ø ProofofincomeforEACHADULT(age18+)inthehousehold.ThisincludescopiesofthelastTWOpaystubs,socialsecurityordisabilitychecks.Youmayalsosubmitcopiesofbankstatementsshowingautomaticmonthlydepositsofgovernmentchecks.Please,noW-2’s.

Ø Ifyouarerequestingthatyourstatusasafulltimestudentbeconsidered,youmustprovideevidenceofenrollment.

Ø DocumentationofANYfederalassistanceyoureceivesuchasfoodstamps,rentsubsidy,orAidtoDependentChildrencashassistance.

Ø FreeorreducedlunchapprovalØ Studentloandocumentation,ifapplicable.Ø Additionalinformationmayberequestedtohelpdetermineneed.

Applicant’sInformation OtherAdultsinHousehold’sInformation

NAME NAME ADDRESS ADDRESS CITY CITY STATE,ZIP STATE,ZIP HOMEPHONE HOMEPHONE CELLPHONE CELLPHONE EMAIL EMAIL DATEOFBIRTH DATEOFBIRTH EMPLOYER EMPLOYER EMPLOYERCONTACTINFO

EMPLOYERCONTACTINFO

DEPENDENTSORADDITIONALADULTSLIVINGINTHEHOUSEHOLD

Name:______________________________GenderMale/FemaleDateofbirth:__________________

Name:______________________________GenderMale/FemaleDateofbirth:__________________

Name:______________________________GenderMale/FemaleDateofbirth:__________________

Name:______________________________GenderMale/FemaleDateofbirth:__________________

Name:______________________________GenderMale/FemaleDateofbirth:__________________

GROSSANNUALINCOMEANDEXPENSES:

HouseholdIncome HeadofHousehold$ AdditionalAdults$ HouseholdExpenses $Employment $ $ Mortgage $ChildSupport $ $ Electric/Gas/Water $GovernmentAsst. $ $ Phone $FoodStamps $ $ MedicalExpenses $StudentLoanIncome $ $ AutoLoan $Other $ $ Other $TOTAL $ $ TOTAL $

Pleasetellusyourstory.Pleasetakethetimetodescribeyourcircumstances/reasonforapplyingforfinancialassistance,includinganyunusualexpensesyoumustmeet.(Attachadditionalpagesifnecessary.)

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Icertifythattheaboveinformationandthesupportingdocumentsarecorrectandcompletetothebestofmyknowledge.IagreetoinformCamp Navigateofanychangesinmyincome,familysize,ormailingaddress.IunderstandthatImayloseallCamp Navigateprivilegesforlackofpaymentorfalsifyinginformationinconnectionwiththisapplication.IunderstandthatmyreducedfinancialassistancewillnotbeautomaticallyextendedbeyondtheawareperiodandthatImustbringupdatedinformationannually,orasrequested,toqualify.Financialassistanceisprovidedbasedonhouseholdincomeandavailableresources.Camp Navigateencouragesfinancialassistancerecipientstowriteabriefnotedescribinghowtheprogramhasbeenofhelptothem.ThesestoriesmaybesharedwithCamp Navigatesupporterstoshowthemhowtheircontributionsareusedandtoencourageprospectivedonorstobecomeinvolved.Wouldyoubewillingtoshareyourstory___Yes___No

Signature_________________________PrintedName_____________________________Date__________