Campership Application Camperships General InformationCamper Name* First Last Parent/Caregiver Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Phone*Email* Enter Email Confirm Email Is your camper already registered for a 2023 Summer Camp Session?*YesNoWhat session is your camper registered in?*Session 1 (June 26-June 29)Session 2 (July 2- July 6)Session 3 (July 9- July 12)Session 4 (July 16- July 21)Session 5 (July 24- July 27)Session 6 (July 30-August 1)Family Camp 1 (August 5- August 7)Family Camp 2 (August 11- August 13)Does your camper receive Regional Center services?*YesNoWhat Regional Center does your camper recieve services through?*Campership ApplicationWhat campership are you applying for?* Partial Scholarship Full Scholarship Amount of financial assistance requested:*Please specify the amount of financial assistance requested. This can be an exact number, or a percentage of the total cost (50%, 75%, etc.)Reason for request:*i.e. statement of financial need, saving respite hours, etc.I understand that each scholarship winner will be asked to formally acknowledge donors with a signed card. Campers and caregivers must approve photo release included in registration paperwork.* I understand I certify that the above information provided is true and correct to the best of my knowledge and understand that it will be held in strict confidence. I understand that in the event assistance is awarded, I am responsible for paying any remaining balance. This balance must be paid for prior to the receipt of services.* I understand Name* First Last Relationship to Camper
