Camper Name *

First Name

Last Name

Camper Date of Birth *

MM

DD

YYYY

Guardian Name *

First Name

Last Name

Guardian Phone *

Country

(###)

###

####

Programs in Which Applicant is Enrolled *

Check all That Apply

Access Pass Program

Child and Adult Care Food Program (CACFP)

Children's Health Insurance Program (CHIP)

Commodity Supplemental Food Program (CSFP)

Healthy Indiana Plan (Basic and Plus)

Hoosier Healthwise Insurance

Low Income Energy Assistance Program

Supplemental Nutrition Assistance Program (SNAP)

Temporary Assistance for Needy Families (TANF)

Traditional Medicaid

Valid Indiana Foster Care License

Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)