We’re glad that you’re taking the time to fill out this campership application. If you'd rather print and fill out this form, you can download a copy here. We believe every child and family should have the opportunity to experience the adventures of summer camp at Camp Lutherhaven regardless of financial situation. We've tried to make it easy to fill out, but if you have any questions, please contact us at camp@lutherhaven.org or (260) 636-7101.

Eligibility is based on your income and the number of people in your household. Please fill out the information below and return it as soon as possible. Gifts will be given out on a first come, first serve basis as funds are available.

Please note that this form is secure and that the information you provide will be treated confidentially and will be used only for determining eligibility. Your prompt and completed application gives you the best chance of receiving financial assistance. You will receive a campership acceptance or denial email within 7 days of submitting it. If you have not yet registered, you will have 14 days to register your child(ren) at which point any campership award will be made available to others needing assistance. If your campership request is denied, you will have the choice for your deposit to be returned or continue with the registration process.

Contact Info

Name of Adult Household Member*

First Last

Email of Adult Household Member

Enter Email Confirm Email

Home Address

Street Address City State ZIP Code

Cell Phone

Home Phone

Work Phone

Camper Info

Campers Applying

Please include all campers for whom you desire financial aid. Add/remove campers by clicking the the +/- icons to the right of a row (bottom on mobile).

Camper's Full Name	Desired Camp Program	Registration Status

Household Names & Income

Household names: Please write the names of EVERYONE living in your house regardless of earning income or not. Include yourself, spouse, children, grandparents, other relatives, and any other unrelated people living in your house.

Income: Include the amount of gross income (if any) that each household member receivedlast month, before taxes or anything else is taken out. Write it in the appropriate income column based on where it came from. If any amount last month was more or less than usual, write that person’s usual monthly income. To determine monthly income, use the following table: If you receive income…

Weekly	Enter weekly amount X 4.33
Twice Per Month	Enter twice a month X 2
Every 2 Weeks	Enter every 2 weeks X 2.15
Annualy	Enter annually ÷ 12

Type 1 (Earnings…)

Wages/Salaries/Tips
Strike benefits
Unemployment compensation
Workman’s compensation
Net income from self-owned business

Type 2 (Welfare…)

Public assistance payments
Welfare payments
Alimony payments
Child support payments

Type 3 (Retirement…)

Pensions
Retirement income
Social Security
Veteran payments
Supplemental Social Security Income

Type 4 (Other…)

Earnings from second job
Disability benefits
Interest/Dividends
Cash withdrawn from savings
Income from Estates/Trusts/Investments
Regular contributions from persons not living in the household
Royalties/Annuities/Rental Income
Any other moneys that may be available to pay for camp

Household Names & Income (List *** EVERYONE *** in your Household)*

Add/remove members by clicking the the +/- icons to the right of a row (bottom on mobile).

Full Name	Type 1	Type 2	Type 3	Type 4	Total Income

Comments

If applicable, please comment on any situation that should be considered in addition to your household income. (eg. extraordinary medical expenses or recent loss of job)

I, hereby, certify and understand…*

By submitting this application, I certify that all income & number in my household have been reported and that the above information is true and correct. I understand that this information is being given for the receipt of campership funds made possible through the generosity of donors.

Name

This field is for validation purposes and should be left unchanged.