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?

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 and street name, city, state, and zip code. Ex: 43 Hill Street 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 DYFS? *

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?

Email of the parent/guardian completing this form: *

Include your email so that we can contact you directly