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Black Lake Scholarship Request
Parent/Guardian Name
First Name
*
Last Name
*
Phone Number
Email
*
Address
Address
*
City
*
ZIP Code
*
State
*
Student Name
First Name
*
Last Name
*
What is your current involvement with Willamette Christian Church?
What is your current involvement with the church?
*
Your involvement is not a pre-requsite for assistance.
Have you received a scholarship before?
*
Select an option
Yes
No
Please state the reason(s) you feel need of aid:
*
The total cost of this camp is
$515
.
I am asking for a scholarship in the amount of:
*
$100 Scholarship
$200 Scholarship
Half Scholarship
Other Amount
Amount
*
Signature
*
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Date
Date
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