2016 Camp Scholarship Application Mail to: PO Box 286, Port Clyde, ME 04855 Phone: 207-372-8677 Fax: 207-372-6377 Herring Gut believes that all children should have the opportunity to experience summer camp, regardless of their financial background. In order to receive financial assistance campers must be year-round residents of Knox County and demonstrate need. All applications are handled confidentially.

Camper’s Name_____________________________________________________

Parent/Guardian 1 Name_____________________________ Relationship to Camper___________________ Phone number:_______________________ Employer_____________________________ Occupation_________________________ Parent/Guardian 2 Name_____________________________ Relationship to Camper___________________ Phone number:_______________________ Employer_____________________________ Occupation_________________________ Does your child receive free lunch at school?□Yes □ No Total family income:

□ $0 to $19,999 □ $20,000 to $39,999 □ $40,000 and above How much are you willing to contribute? _______ Each scholarship amount will vary based on each camper’s need. I certify that all of the above information is true and correct. Parent/Guardian signature__________________________________ Date____________ Herring Gut Learning Center does not discriminate on the basis of race, ethnicity, gender, sexual orientation, disability, nationality, political affiliation,  age, or religious beliefs in the administration of its education programs. 

2016 Scholarship Application

Permanent Address_______________________________________________________ City_________________________ State___________________ Zip_______________