EVERY CHILD DESERVES TO GO TO CAMP

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1 EVERY CHILD DESERVES TO GO TO CAMP Camper Scholarships YMCA Camp Silver Beach s mission is to ensure that no child is ever denied the golden experience of a fun-filled week of summer camp due to his or her financial inabilities. With breathaking woods, wetlands and the Chesapeake Bay as a backdrop, this Eastern Shore treasure is everything a camp should be. It s not just the swimming, climbing, sailing and adventure. It s the connections kids make at YMCA Camp Silver Beach with each other, themselves and the environment. Each year, the YMCA of South Hampton Roads provides over 7 million in financial assistance. These funds are made possible through the generous gifts from the community, our members, volunteers and donors to the annual giving campaign. YMCA OF SOUTH HAMPTON ROADS

2 SECTION 1: HOUSEHOLD INFORMATION AND INCOME Parent/Guardian Name Home Address Home Phone Cell Phone City State Zip Address Names and ages of all people living in household FINANCIAL CIRCUMSTANCES ADJUSTED GROSS HOUSEHOLD INCOME Please tell us the amount you can pay. Line 37, Form 1040 Please tell us your reason for requesting assistance. If adults in the household file separately, please add line 37 from each form 1040 together and enter the total above. SECTION 2: CAMPER INFORMATION SECTION 3: REQUESTED DOCUMENTATION 1040 FEDERAL INCOME TAX RETURN: In order to provide financial assistance in a fair and consistent manner, you must attach your most recent 1040 return. If you file Married Filing Separately, please provide both returns. I certify that all information on my application is true and complete to the best of my knowledge and any misrepresentations may result in autmomatic termination of finaicial assistance and future applications. Failure to provide updated income documentation when requested will result in the full program fee being applied to my account. I understand that my financial assistance will expire at the end of the program session. I agree to notify the YMCA if my fiancial situation changes, so that my application can be re-evaluated. I understand that financial assistance is awarded on a first-come, first-served basis, subject to available funds and eligibility. I understand that the YMCA of South Hampton Roads is a nonprofit organization and that financial assistance is made possible through the generosity of donors. I understand that expiration or revocation of my subsidy does not automatically cancel my program enrollment. Applicant Signature Date PO Box YMCA Lane, Jamesville VA (757) or toll-free (877) Page 2 of 5

3 YMCA Camp Silver Beach 2017 Summer Camp Scholorship registration Form Camper Information: Camper name: Name called: Sex: Home address: City: State: Zip: Male Female Age at camp: Birth date: mm/dd/yyyy Rising grade level: (Fall 2017) Name of school: Has this camper attended CSB before? no How did you hear about CSB? School Family Friend Radio TV Mail Website YMCA Camp Fair (which?) Other If you are a YMCA member, to which Y do you belong? **If possible, my camper would like to have the following cottage mate: (Cottages are assigned by age and grade level. Cottage requests must be mutual.) **Camp Silver Beach administration believes meeting new friends and experiencing diversity is an integral part of the camp experience and reserves the right to determine cottage placement. I would like to register for the YMCA Camp Silver Beach sessions checked below: ONE-WEEK CAMPS Session 1 6/11 6/17 Session 2 6/18 6/24 Session 3 6/25 7/1 Session 4 7/2 7/8 Session 5 7/9 7/15 Session 6 7/16 7/22 Session 7 7/23 7/29 Session 8 7/30 8/5 Session 9 8/6 8/12 Session 10 8/13 8/19 Traditional Camp (ages 8 16) 870 t Available t Available 870 Expedition Camp (ages 13 16) t Available t Available 1,020 Rock & Raft 1,020 Coastal Trek 1,020 Blue Ridge Hike t Available t Available t Available t Available t Available MULTI-WEEK CAMPS Traditional Two-Week Camp (rising 6th 8th graders) t Available 1,700 TW1 6/25 7/8 1,700 TW2 7/9 7/22 t Available t Available Teen Adventure Camp (rising 9 11th graders) t Available 2,625 TAC1 6/25 7/15. 2,625 TAC2 7/16 8/5. t Available Leadership Development (rising 11th graders) t Available 2,625 LDP1 6/25 7/15. 2,625 LDP 2 7/16 8/5. t Available OPTIONAL CAMP ADD-ONS SCHOLORSHIP FUNDS NOT AVALIBLE Can be added on to traditional one-week or two-week camps. Ski School (ages 8 16) 100 t Available t Available t Available t Available 100 Specialty Camp (ages 11 16) Please circle one specialty topic for each session. t Available t Available Culinary or Water Sports Science or Boating Sailing or Lifeguard Culinary or Water Sports Science or Boating Sailing or Lifeguard t Available t Available Session Preference: Total Camp & Add-On Fees Minus YMCA Member Discount (100/session) With limited funding avalible for each session it is possible that your prefered session may be unavalible. To prevent delays to your childs registration please indicate your 1st, 2nd, and 3rd session chioce. We will contact you with the session that is avalible. 1st 2nd 3rd Total Amount Due PO Box 69, Jamesville, VA P F Register online! W campsilverbeach.org E Page 3 of 5

4 Transportation: Offered only to campers arriving by plane or bus. Transportation fees are due at the time of registration and are nonrefundable. Camp Silver Beach to rfolk International Airport rfolk International Airport to Camp Silver Beach Parent/Guardian Information: Mother/Guardian Name: Responsible Party? Address: Father/Guardian Name: Primary Guardian? City: State: Responsible Party? Address: State: Zip: Primary Guardian? City: Zip: In event of an emergency, contact (other than parent): Other addresses wishing to receive updates: Every child or teen deserves to go to camp! When you give to YMCA Camp Silver Beach, you are ensuring that children have the opportunity to develop confidence, make friends and discover their potential. As the nation s leading nonprofit for youth development, healthy living and social responsibility, the Y uses your gift to make a meaningful, enduring impact on the lives of 200 campers each year. Your tax-deductible contribution can be made as a one-time gift or be drafted monthly from your checking account or credit card., I will help send a child to YMCA Camp Silver Beach, with my gift of: 1,000 (Banner level: Put your child s name on the wall and show everyone your support.) 500 Page 4 of Other

5 Fees Worksheet: Please total the amount due. Registration total from page 1: Transportation Fees from page 2: Tax-Deductible Contribution from page 2: Total Amount Due: Step 2: Payment Plans Payment in full Deposit only (200/session and ski school fees) with balance due by May 15, 2017 and I authorize CSB to charge/ draft my camper s balance on May 15, Deposit only (200/session and ski school fees) with balance due by May 15, I will provide payment of balance by May 15, Monthly Payment Plan: # monthly payments of automatically drafted on the 15th of each month with final payment drafting no later than May 15, First month s draft will be on date of registration. Step 1: Payment Method Check enclosed Mastercard Step 3: Account Details Cardholder/Accountholder Name: Credit Card Number: Bank Draft American Express Visa Discover Expiration Date: Bank Draft Routing #: Account #: Security Code: Step 4: Payment Authorization I authorize my bank (or credit card institution) to honor preauthorized Electronic Funds Transfer drawn by the YMCA of South Hampton Roads on my account for payments as indicated on page 3 of this application. When the bank honors the EFT by charging my account, such transfer shall constitute notice of payment due and my receipt for the payment. Should any preauthorized EFT not be honored by said bank when received by them, then it is understood that payment is to be made by me in the amount of said payment plus service charge. It is further understood that if such payment is not honored by the bank or credit card institution, then the YMCA of South Hampton Roads, at its discretion, may resubmit the amount due for payment on a future date. Accountholder/cardholder signature... Date (mm/dd/yyyy)... Please read and complete the following: Application MUST be signed for camper to be enrolled. I hereby request that my child (child s name) be accepted to attend YMCA Camp Silver Beach. I understand and am aware that my child will be participating in many physical activities and that the potential for accidents does occur. In consideration of acceptance to YMCA Camp Silver Beach, I indemnify and hold harmless Camp Silver Beach, the YMCA of South Hampton Roads, and/ or its staff, directors and officers from any and all liability, claims, damage, injury or illness sustained by my child, and I grant permission for Camp Silver Beach to provide or obtain medical attention for my child in the event of sickness or injury, and I understand accident insurance is not included in the camp fee. Should a camper require special medical treatment, prescriptions, or hospital care during the camp session, parent(s)/guardian(s) shall bear the expenses. I understand that a current CSB Health & Medication Form, found at CampSilverBeach.org, must be submitted to the camp office prior to my camper s participation. The form must include a physical exam date within 12 MONTHS of his/her time at camp and be signed by the examining medical professional. I agree that Camp Silver Beach may photograph and/or film my child for use in promotional and communication materials. I understand that as a registered Ski School, Teen Camp or Leadership Development Program participant, my child will be leaving Camp Silver Beach property in CSB/YMCA approved vehicles to area destinations for specialized programs. I understand that my child may participate in these activities: archery; riflery; skateboarding; roller blading; basketball; roller hockey; flag football; arts & crafts; paddleboarding; motor boating; swimming; sailing; kayaking, field sports; soccer; softball; volleyball; tennis; martial arts; dance; drama; music; waterskiing; Environmental Discoveries; Zip Line and Alpine Tower. If choosing a monthly payment plan, no deposit is necessary to secure your camper s spot. Monthly payments are made using automatic credit card or checking account draft beginning in the month of registration; please include credit card or checking account information above. If choosing to pay the balance by May 15, 2017, a 200 deposit per session is required to secure your camper s spot. All camp fees are due and must be postmarked by May 15, You will receive periodic billings for your balance. If Camp Silver Beach is notified of cancellation prior to May 15, 2017, a 100 cancellation fee per session applies. If Camp Silver Beach is notified of cancellation after May 15, 2017, a 200 cancellation fee per session applies. If you register your camper after May 15, 2017, you are required to pay the full amount at the time of application. All returned checks are subject to a 25 service charge. Cash, personal checks, Visa, Mastercard, American Express or Discover are accepted for payments and deposits. Applicants who cannot be accepted due to a full session are notified and advised to select another session or join a waiting list. Cancellations do occur, and waiting list campers advance in the order applications are received. Additional information regarding transportation, what to bring, camper health forms, etc. will be made available online. A Parent Guide to help you prepare more effectively for your child s camp experience will also be available at Admission as a Camp Silver Beach camper carries many privileges and responsibilities. We expect campers to participate in the total life of camp to work, play and live together. We do not allow the use of tobacco, alcohol, illegal drugs, or weapons (other than arrows and rifles provided for camp activities under staff supervision). Application signifies understanding and acceptance of these responsibilities; violators will be dismissed without a refund. In addition, should a behavior or discipline problem affect our work with other campers or their enjoyment of Camp Silver Beach, we reserve the right to dismiss those campers responsible, without refund. Parent/guardian signature... Date (mm/dd/yyyy)... Page 5 of 5

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