COUTTS-MORIARTY CAMP, INC. 2008 SCHOLARSHIP APPLICATION

PLEASE RETURN THIS FORM WITH YOUR CAMP REGISTRATION
Mail to: Coutts-Moriarty Camps, c/o Siskin EA, PO Box 1, East Charleston, VT 05833

Information on this form is confidential and will be reviewed only by the Scholarship Selection Committee. The objective of the Scholarship Program is to help families provide an exciting camping experience for their children. Scholarships are available for all of our camps.

A $40 deposit for each camper is required to hold a spot for your child.
You will be notified as early as possible of the amount you have been awarded.

Scholarship amount you are requesting ___________

Camper(s) name ________________________________________________________________

Parent/Guardian Name ___________________________________________________________

Mailing Address ________________________________________________________________

Town of Residence ________________________________________________

Telephone Number ________________________ Email _______________________________

Number of children at home:________ Number of adults at home ______
Number of children who wish to attend camp this summer: _____ Resident   _____Day Camp
Have your children ever received a Camp Scholarship? ______Yes ______No
Mother/Guardian Occupation ______________________________________________________
                        Employer ________________________________________________________
Father/Guardian Occupation _______________________________________________________
                        Employer ________________________________________________________

Family Income Range:            under $10,000                        $20,000 - $25,000            $35,000 - $40,000
(circle one)            $10,000 - $15,000            $25,000 - $30,000            $40,000 - $45,000
                                    $15,000 - $20,000            $30.000 t-$35,000            $45,000 - $50,000
                                                                                                            $50,000 and over
*Please attach a note explaining any unusual family circumstances.

Parent/Guardian Name (please print)_______________________________ Date _____________

Parent/Guardian Signature______________________________________________

FOR OFFICE USE ONLY

Scholarship awarded _____________________ Date:________________________

Deposit paid:______________ Check number________________