Camper Information

Camper First Name *

Camper Last Name *

Gender *

Birth Date * +

Age on July 30, 2023 *

Address *

City, State, Zip *

Parent/Guardian Name *

Parent/Guardian Cell Phone *

Parent/Guardian Work Phone *

Parent/Guardian Home Phone *

Parent/Guardian Email Address *

Is Parent:? *

Hearing

Deaf

Is Parent:? *

Hearing

Deaf

Child Background Information:

Has this child attended Camp Sertoma in a previous year? If yes, please list which year(s): *

No

Yes (if so, please list which years) Yes (if so, please list which years)

So that we can assure the best pairing of campers and staff during the week:

Is this child: *

Deaf

Hard of Hearing

Signing CODA or sibling of a Deaf child* (please indicate deaf relative's name and relationship to child) Signing CODA or sibling of a Deaf child* (please indicate deaf relative's name and relationship to child)

How does this child access communication at school? *

How does this child communicate with others at school? *

How does this child communicate with your family? *

What, if any, hearing device does this child use? *

Cochlear Implant

Hearing Aid

Bone Conduction Hearing Device

Other (please describe) Other (please describe)

What, if any, additional support for behavior or additional disability does your camper receive while at school or play? Include any special medications or medical treatment he/she receives on a daily basis. (This question is only to help us plan appropriate staff, and not to limit attendance at camp.) *

Is there anything you would like us to know that will help your child feel welcome and safe at camp? *

Other:

In special circumstances, we *may* be able to arrange for your camper to share a cabin with a friend of the same age, to allow for both to have the best camp experience. What is the name of the other camper? *

What is your child's t-shirt size? *

CAMP SCHOLARSHIPS are available to families who are unable to pay the total cost of a camp experience. Do you wish to apply for a full or partial scholarship for this child? (If "yes" please complete the Scholarship Application section) *

Yes

No

Do you need assistance in transporting your child to/from camp? (Please note there is not a standard "bus service" for camp. This option is reserved for families who either do not have their own method of transportation or who live far away from camp; in which case in some areas, Sertoma volunteers may be available to assist you with transportation of a limited number of children from North Carolina, Virginia and Maryland.) *

Yes

No

BEFORE THIS APPLICATION BE ACCEPTED, WE WILL NEED TO RECEIVE THE $50 PER CHILD APPLICATION DEPOSIT. ONCE YOU SUBMIT THIS APPLICATION ONLINE, WE WILL SEND YOU AN EMAIL WITH AN INVOICE FROM WHICH YOU CAN PAY THIS DEPOSIT. ONCE THE DEPOSIT PAYMENT IS RECEIVED, WE WILL PROCESS YOUR APPLICATION PROMPTLY. THANK YOU!

PLEASE NOTE: A priority registration will be used for Deaf/HH campers. This registration modification will help ensure that a balance of Deaf, hard of hearing, and hearing CODA campers is maintained at each age level - which helps us plan for staffing and activities to make sure your camper has the best access to camp. Deaf/HH camper applications will be reviewed immediately upon receipt; hearing CODA applications will be placed on a waiting list and reviewed beginning May 1. Apply today, space is limited!

Scholarship Application

Total number of family members in household (include individual making request):

Parent Occupation

Total Family Income (gross before taxes):

Potential Number of Family Members Attending Camp

Total Amount of Camp Scholarship Requested

Has the camper's application deposit fee ($50 per child) been paid?

Yes

No

Has this camper received a scholarship to attend Camp Sertoma in a prior year?

No

Yes (if so, please indicate amount) Yes (if so, please indicate amount)

Describe the reason for your request and how you expect your child to benefit from a camping experience.

A Camp Scholarship is also sometimes referred to as Tuition Assistance, Financial Aid or a Scholarship.

Please note that full tuition for the 2023 camp is $575 per camper. If you have paid the application fee of $50, the maximum scholarship you can apply for is $525 per camper. Scholarships can only be used to assist with tuition fees and cannot be granted to cover late application fees or camp store purchases. Note that applications received by April 15 will receive an early bird discount of $50!

Supplementary financial assistance is granted based on the information provided. Please be advised that there is no guarantee that if a camp scholarship is offered, that it will be in the full amount requested. Each application will be reviewed individaully, and parents/guardians will be contacted accordingly.