Summer Camp - Seeds of Success Application Parent / Caregiver Name * First Name Last Name Student Name * First Name Last Name Student Age * What school and district does your student attend? * Email * Phone (###) ### #### Address Which camp are you applying for? * Natural Scientists (July 21-25) Earth & Animals (July 28- August 1) Today's Date * MM DD YYYY Please select your ethnicity The following information is for our own internal reporting purposes and does not affect the status of your program participation. We do not share any personal information publicly Hispanic Non- Hispanic I do not wish to disclose Please select your race The following information is for our own internal reporting purposes and does not affect the status of your program participation. We do not share any personal information publicly White Asian Black or African American Native Hawaiian or Other Pacific Islander American Indian or Alaska Native I do not wish to disclose bi racial/ multi racial How would you describe where you live? Urban Area Rural Area We understand that financial circumstances can vary. If you or your household are facing challenges that make it difficult to pay the full program fee, please let us know. You may be eligible for a discount. If you’re comfortable, please feel free to share any details about your situation that may help us better understand your needs. * Are you currently receiving any of the following public benefits? * SNAP, WIC, or Food Stamps Medicare/ Oregon Health Plan (OHP) Temporary Aid for Needy Families (TANF) Financial Assistance- SSI Social Security- SSDI Public Housing None of the Above Other Electronic Signature: I have given the information above and to the best of my knowledge it is true and accurate. I agree to allow Parker Learning Gardens to contact any/all the above mentioned agencies to verify my participation. I have read and agree with the statement above Thank you! You will receive an email with in 7 days of submission. If you do not, please email info@parkerlearninggardens.org
