BRHP | Summer Camp Assistance Application

BRHP will cover a portion of summer camp costs to the extent funds are available for children in your household, 5 to 17 years of age, up to $1,000.00 per household. This year, BRHP is requesting that participating families do the following: Contribute $50 per child. Select a camp from one of the summer camp options available in the application. BRHP has selected these camps based on popularity among families and for ease of payment. If your desired summer camp is not listed, please select “other” and provide the required eligibility documentation. *Funds are available on a first come, first served basis.

Complete Application Below:

Parent or Guardian Contact Information

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Phone

Cell Phone

Email

Are you a member of the Y of Central Maryland?*

Yes
No

Summer Camp Registration Information

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Assistance Needed:

Child's Name*

First Last

Child's Age*

Child's Grade (Next School Year)*

Selected Camp*

What is your Y of Central Maryland member ID?*

If you selected "other," please include the name and website of your chosen camp.

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Camp Name

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Camp Phone Number

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Camp Contact Name

First Last

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Camp Address

Street Address Address Line 2 City State ZIP Code

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Camp Billing Address (If same as camp address, leave blank)

Street Address Address Line 2 City State ZIP Code

For how many weeks do you need assistance?*

In the following list, enter the week that you need assistance for and the cost for that week. If you need assistance for more than 1 week, select the + Ex. Dates: 07/05/23 – 07/09/23, Cost: $150

Camp Dates and Weekly Costs*

Dates:	Weekly Cost:

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Copy of Camp Flyer or Brochure

Max. file size: 50 MB.

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Camp Website

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You are applying for assistance for more than one child ?

Please keep in mind that requests for assistance may not exceed $1000 total.

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Assistance Needed:

Child's Name*

First Last

Child's Age*

Child's Grade (Next School Year)*

Selected Camp for Second Child*

If you are not requesting assistance for more than one child, please leave this section blank.

If you selected "other," please include the name and website of your chosen camp.

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Camp Address for Second Child

Street Address Address Line 2 City State ZIP Code

If you are not requesting assistance for more than one child, please leave this section blank.

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Camp Billing Address for Second Child (If same as camp address, leave blank)

Street Address Address Line 2 City State ZIP Code

If you are not requesting assistance for more than one child, please leave this section blank.

For how many weeks do you need assistance?*

Camp Dates and Weekly Costs*

Dates:	Weekly Cost:

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Copy of Camp Flyer or Brochure

Max. file size: 50 MB.

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Camp Website

Data Sharing*

I agree to allow BRHP to share income information with third parties in order to determine income eligibility.

Family Contribution*

I agree that if my application is accepted, I will pay $50 to BRHP towards the summer camp fees.

Signature

Today's Date

Summer Camp Assistance Application

Summer Camp Assistance Application

Complete Application Below:

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