2021 Scholarship Application Question Title * 1. Applicant's Information Name Date of Birth Address City/Town State Zip Code Question Title * 2. Camp/Activity Information Name of Camp/Activity Date(s) of Camp/Activity Contact Person Mailing Address Phone Number of Contact Person Email of Contact Person Total Cost of Entire Camp/activity Date Payment is Due Special Notes or Information (if any) Question Title * 3. Parent/Guardian Contact Information Name Address Address 2 City/Town State/Province ZIP/Postal Code Email Address Phone Number I agree that this is a one-time, per calendar year request and is subject to approval. Upon approval, the payment will be issued directly to the camp or activity attended. I have read and understand the DSAGT Scholarship Guidelines. Upon my printed and signed name below, I agree to these stated terms. Question Title * 4. Name Below will serve as electronic Signature Individual, Parent or Legal Custodian Name (printed) Date Done
