Max and Cecilia Rosenheimer

Camp Scholarship Fund Application

Name of Camper _______________________________________________

Parent/Guardian Name(s) ________________________________________

Email Address ______________________________Phone _____________

Street ________________________________________________________

City _________________________State _________Zip ________________

Summer Camp your child will be attending ___________________________

Date(s) of Summer Camp Session(s) ____/____/12 to ____/____/12

Cost of attending camp __________________________________________

Other scholarships and financial assistance for which you are applying:

_____________________________________________________________

Please briefly explain your need for financial assistance:

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

Applications must be received by Friday, March 16, 2012. Please either mail or email your completed application to:

Rabbi Shalom Bochner, Director of Lifelong Learning
Congregation Netivot Shalom
1316 University Avenue, Berkeley, CA 94702
education@netivotshalom.org
Questions? Call 510-549-9447, ext. 104