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,. City of Sunny Isles Beach Cultural & Human Services Department l8070 Collins Avenue Sunny Isles Beach, Florida 33160 (305) 792-1706 (305) 792-l566 fax t Iff Summer Camp '07 Financial Assistance Application Form G enera ar IClpan norma IOn Date: Last Name First Name Birth Date Which camp(s) are you o Tot.Lot o SIB Sex: ./ 0 Male enrolling your child in? o Adventure o Jr. Lifeguard Check One 0 Female o Basketball o Cheerleading o Soccer Parent Information Mother's Name Father's Name . ",~""M'_'_"_'H'H'_ '........H........... ............."'...."..""."............... .."..,,_'............n. ................. ....... ...... .. ...................... ... .............. .........................,.. ............ ........ ....-................. ............H..................... ,.................. ................. .......n......._."...................._......._.. Address Address .......H...."........._..._... ... ................. h..........................,.... ,,,..................,...... ..,........"..............,.....".....H w.........,.......... ....".... ""....M.". ........................"....... ................ ... .......... ... ............ .... ......., ..._._.."...H..."H"..~....~.H.H".... ......... ..... "'H'~"'" City, State, Zip City, State, Zip ..H._._...._._......". .~.H...H....,~._.~....~__ _.~~~..~..._~.H.~~...__._ 'H.._.~~.___~.._. ........H..._~._....._......,...._ ............- ........... ...........,..._....~_....._,_.- ........_......._.H. -..... .. ... ..~... .. ..... ,~ .....- .....-. ..............-...- .....h... ...........-.. ........ ........-..........--....... ...... ..-. H...._.._.. Home Ph # ( ) Home Ph # ( ) Who has child custody: 0 Both 0 Other *(explain) *Must provide legal ./ Check One 0 Mother * documentation if a parent has 0 Father * restricted parental rights. Household Information: Total household size: # of adults: # of children: I I ~ f ( 'd f 2006 I T Rt ncome norma IOn: must prOVl e copy 0 ncome ax eurn Mother's Employment Information: (Name, Address and Phone Number) Mother's Annual Occupation: Income: Father's Employment Information: (Name, Address and Phone Number) Father's Annual Occupation: Income: Do you D Medicaid * D Food Stamps * D Other governmental assistance * In the amount of: * Please provide recei ve: verification with application. Expenses: (copy of lease or mortgage payment statement may be requested) Do you own or rent your home? Down D rent Other unusual expenses: Monthly payments: Amount: Extenuatin Circumstances: Please state any special circumstances that may qualify you for assistance. I certify that all of the information herein is correct: I Print name: I Signature: I Date: You must return this application form, along with a copy of your 2006 Income Tax Return to the Cultural & Human Services office by April 20th. This form does not guarantee a reservation for your child in summer camp. You must also register your child (registration fee and 10% deposit of camp fees required) in order to hold a space for the summer.