Kidspace Summer Camp Scholarship Application

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* 1. Please provide the following information based on the parent or caregiveer completing this form and responsible for the child during Kidspace Camp Hours

Name:

Address:

Address 2:

City/Town:

State:

ZIP:

Country:

Email Address:

Phone Number:

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* 2. Child's Full Name

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* 3. Age of child at time of Kidspace Camp

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* 4. Name of school that child is attending during the 2012-2013 school year

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* 5. Number of persons in household

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* 6. Total annual household income

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* 7. Own or Rent?

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* 8. If needed, what type of documentation are you able to provide as proof of income and household size?

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* 9. Summer Camp at Kidspace is 5 weeks long. This scholarship is for one week only. Please rank all 5 weeks in order of preference if your child receives a scholarship. If there is a week when your child can not participate, please note it on the comments below. Remember that if you receive a scholarship you must commit to bringing your child for all 5 days from 9am to 5pm.

Week 1--Wacky Kitchen Science (7/15-7/19)

Week 2--Physics Camp (7/22-7/26)

Week 3--Water Water Everywhere (7/29-8/2)

Week 4--JPL Outer Space Camp (8/5-8/9)

Week 5--Chemistry of Art (8/12-8/16)

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* 10. All scholarships are awarded based on need. Income verification may be required. Please use this space for any comments you would like to share with us regarding this application.