Outdoor Outreach Summer Adventures: Tuition Assistance Questionnaire

Basic Information

Parent/Guardian First Name:

Parent/Guardian Last Name:

Parent/Guardian Phone Number:

Parent/Guardian Email:

Participant's First Name:

Participant's Last Name:

Participant's Age:

Summer Adventures Session Dates:

Address Line 1

Address Line 2

City

State

Postal Code

Household Information

Our family resides in one of the following six zip codes: 92102, 92105, 92113, 92114, 92115, 92139

YesNo

Our family qualifies for free or reduced lunch.

YesNo

My child(ren) has/have participated in an Outdoor Outreach program before.

YesNo

Our family's Annual Gross Income is:

Our family household size is:

I am willing and able to pay the following amount for this program:

What amount are you willing and able to pay for this program?

Please provide a brief statement of need (200 character limit).

Military Status

Did one or more Parent(s)/Guardian(s) serve in the US Military?

Status

Branch of Service

Signature

Please provide your name confirming that the information you provided above is true.

Please initial to confirm your agreement to pay at minimum a tuition assistance fee of $20.00 for each child registered. This fee is non-refundable.