Am I Eligible- Summer Camp Application

General Details

Parent(s) must be a legal residence of Palm Beach County. Enter Zip Code:

Please enter head of household date of birth:

Additional household members not counting yourself:

Member #	Date of Birth
Member 2		Does the child present with Special Needs? Yes No Member of specialized population? Yes No
Member 3		Does the child present with Special Needs? Yes No Member of specialized population? Yes No
Member 4		Does the child present with Special Needs? Yes No Member of specialized population? Yes No
Member 5		Does the child present with Special Needs? Yes No Member of specialized population? Yes No
Member 6		Does the child present with Special Needs? Yes No Member of specialized population? Yes No
Member 7		Does the child present with Special Needs? Yes No Member of specialized population? Yes No
Member 8		Does the child present with Special Needs? Yes No Member of specialized population? Yes No
Member 9		Does the child present with Special Needs? Yes No Member of specialized population? Yes No
Member 10		Does the child present with Special Needs? Yes No Member of specialized population? Yes No

Enter Total Annual Gross Income

Income includes:

Employment
Social Security (SSI/SSD)
VA Benefits
Unemployment Comp
Worker’s Compensation
Child Support
Self - Employment (taxes)
Other Sources (TANF/Pension)

Note: Children of specialized population are Homeless, Foster, DJJ, DJJ/Sibling, Bridges-SRP and Special Needs(Autism, Asperger or related disabilities)

Disclaimer: This calculation is only an estimate. Eligibility is dependent upon review of the supporting documents.

Am I Eligible?