top of page
Virtual Advocacy Office
Bernice's Place Summer Camp Application
To register for assistance, please complete this form to the best of your ability.
All of this imformation is necessary to determine eligibility for assistance.
Parent's Information
First Name
Middle Name
Last Name
Email
Address
Phone Number
Date of Birth
Last 4 Digits of Social Security Number
Gender/Sex
Source of Income
Employment/Working
Unemployment
SSDI
SSI, GA, or TANF
Child or Spousal Support
Retirement/Pension
Other
Citizenship
Are you a Veteran
Housing Status
Individual/Family Type
Choose the option that best describes your household
What is your total anual income?
Are you or anyone in your household pregnant?
Yes
No
Are you survivor of domestic violence?
Yes
No
Do you recieve any non-cash benfits?
SNAP (Food Stamps)
Medicaid
Medicare
WIC (Speical Supplemntal Nutirition for Woman, Infants, and Children)
Section 8, Public Housing, or Other Ongoing Rental Assistance
Temporary Rental Assistance (TRA)
Other Benefits
No Benefits
Has anyone in your household been affected by any of these?
Physical Disability
Developmental Disability
Chronic Health Condition
Mental Health Issues
Subtance Abuse
No Disability
Full Name of Emergency Contact #1
Relationship to Children
Emergency Contact Phone Number
Alternate Drop-off Address #1
Full Name of Emergency Contact #2
Relationship to Children
Emergency Contact Phone Number
Alternate Drop-off Address #2
Continue
bottom of page
