Fresh Air Fund Application Form

Name of Camper *

First

Last

Boy or Girl? *

Boy
Girl

Date of Birth *

(month/day/year)

Age *

How old is this camper?

Name of Parent/Guardian *

First

Last

School *

Which school did the camper attend this past year?

Grade *

Home Phone Number *

Put in the format 123-456-7890

Parent/Guardian Cell Number *

Put in the format 123-456-7890

Parent/Guardian Work Number. *

Put in the format 123-456-7890. Include extension if needed.

Home Address *

Include house number, street name, city, state, zip code and apartment / Floor number if applicable. Ex: 43 Hill Street, apt. 1 Newark, NJ 07102

In an emergency, contact:

First

Last

Emergency Contact Phone Number *

Put in the format 123-456-7890. Please include extension if needed.

Are both parents living at home? *

Yes
No

If not, which one is not? *

Mother doesn't live at home.
Father doesn't live at home.
Does not apply; both parents at home.

Gross family income per year? ($) *

What is the total income made by entire family?

Number of children in the family *

Are you receiving assistance from Welfare, Social Security, or DCP&P? *

Yes
No

If Yes, what is your monthly award? ($) *

(If no, put "0" in this field.)

HEALTH HISTORY - Has you child had a major recent illness or surgery? *

Yes
No

If Yes, what illness or surgery did they have?:

(If No, put "N/A" in this field.)

Does your child have any allergies? *

Yes
No

If Yes, what allergies does this child have?

(Please list all allergens for this child. If No, put "N/A" in this field.)

Why would you like this child go to a Fresh Air Fund camp? *

Reason for recommendation (please be as detailed as possible)

Has this child attended camp before? *

Yes
No

If Yes, which camp and what year?

Please tell of some special facts about your child: *

What your child's favorite food or snack? What is your child's favorite subject? What does your child like to do for fun or entertainment? Favorite sport? Favorite activity? Favorite character? Does your child have a hero? How does your child like to spend their free time?

What summer camp activity is your child looking forward to the most? *

Email of the parent/guardian completing this form: *

Include your email so that we can contact you directly