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2010 FCA CAMP SCHOLARSHIP REQUEST FORM

Camper's Name: ____________________________________________         

Parent's Name:   ____________________________________________       

Address: ______________________________________________               

E-mail: __________________________________________________       

Home Phone: _____________________________________________     

Office Phone: _____________________________________________    

School: _____________________________________   Grade: _____


1.  What camps are you interested in attending?                           Main Sport?

2.  What scholarship amount do you feel you need in order to attend camp?

3.  Have you attended a FCA Camp in the past?  Have you received an FCA scholarship before?  If so, what year(s) and amounts?

4.  Parents combined 2009 gross income: (Please circle appropriate amounts)
 "Under $20,000"    "$35-50,000"   "75,000 & Above"    "$20-35,000"   "$50-75,000"

5.  Other Siblings and ages:

6.  Do you have a FCA Huddle at your school?  If so, are you actively involved?

7. If no FCA Huddle at your school are you willing to help FCA start at you school?


8. If asked, are you committed to be an officier for your school's huddle?


Signature: ______________________________________  

Date: ___________________   

Please Complete and fax or mail to our local FCA office.

FCA Tampa Bay
9617 North Trask Street
Tampa, Florida 33624
813-504-4834
813-769-9961 fax