Fee Assistance Application

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WI-NE-MA CHRISTIAN CAMP

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Fee Assistance Application

* Indicates required field

Parent/Guardian Name *

First

Last

Phone Number *

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Number of People in Household *

Church Home (if applicable) *

Number of Dependent Children *

Number of Children in Household Attending Camp *

Camper Information

Camper 1 Name *

First

Last

Date of Birth *

Camp Session *

First Time at Wi-Ne-Ma Christian Camp? *

Yes No

Camper 2 Name *

First

Last

Date of Birth *

Camp Session *

First Time at Wi-Ne-Ma Christian Camp? *

Yes No

Camper 3 Name *

First

Last

Date of Birth *

Camp Session *

FIRST TIME AT WI-NE-MA CHRISTIAN CAMP? *

Yes No

Circumstances

Have you applied for assistance from other sources? *

Yes No

Special CIrcumstances *

Single Parent Household Recent Job Loss Uninsured Medical Expenses A Child Diagnosed with Special Needs in the Home

Other Circumstances *

Finanacial Information

Household Gross Annual Income *

Total Amount Requested *

I verify that all information on this form is true and correct to the best of my knowledge.

Parent/Guardian Electronic Signature *

Date *

Submit

Contact Us

5195 Winema Road
Cloverdale, OR 97112
503-392-3362
winema@winema.org

Location

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Home
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Youth Camps
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