FCA San Diego UCLA Camp Scholarship Request form

Name of Camper

Camp Sport This Year?

Camper's Home Address

Camper's Email Address

Camper's Home Phone Number

Camper's Cell Phone Number

Camper's Date of Birth

Camper's Parent/Guardian Name

Relationship To Camper

Parent/Guardian Best Phone Number

Parent/Guardian Email Address

Parents Combined Gross Income for 2019

Camper's High School

Grade Camper Will Enter in Fall 2020

What is the name of Camper's FCA Area Rep or Coach?

Which Scholarship Amount is Camper Applying for?

Have you received an FCA Camp Scholarship in the past? Amount of Past Scholarship? Which Year(s)?

Is There an FCA Huddle at Camper's School? Is Camper Actively Involved?

Why do you think that you would be a good candidate to receive this scholarship?

Jordan Dietze

San Diego County

Director

(760) 402-2940

jdietze@fca.org

San Diego County FCA

PO Box 2429

Carlsbad, CA 92018