Apply

Organization/Agency/Group Referral

Name of Agency/Organization/Group:
Person, title, making the referral:
Phone:
Email:

Family Information

Name of parent/guardian:
Phone:
Email:
Mailing Address for check:
Rural families requesting a $50 gas card: NoneMobilShell

Camp Information for each child

Name/location of camp:
Name of child who will be attending:
Age:
Gender:
Dates of camp week:
Cost of camp week:

Name/location of camp:
Name of child who will be attending:
Age:
Gender:
Dates of camp week:
Cost of camp week:

I attest that the Foundation for Community Justice will be promoting healing and recovery by awarding this scholarship.
Signature of group/agency representative: