Youth's Name Youth's First Name Middle Name Last Name Contact Email Daytime Phone Gender Female Male Home Address Address City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWashington DCWest VirginiaWisconsinWyoming ZIP/Postal Code What grade will your child enter in the fall? Kindergarten First Grade Second Grade Third Grade Fourth Grade Fifth Grade Sixth Grade Seventh Grade Eighth Grade Ninth Grade In the event I cannot be reached or cannot pick up from camp, my child may be released to: I/we authorize Penn State Altoona personnel to photograph, videotape, and/or audiotape my/our child in promotion of Penn State’s program and/or Investment Savings Bank Endowment fund. Yes No First Camp Choice Camp Title Age or Grade Level Beginning Date and Time Beginning Date and Time: Date Beginning Date and Time: Time Second Camp Choice Camp Title Age or Grade Level Beginning Date and Time Beginning Date and Time: Date Beginning Date and Time: Time Household Information Number of adults in the home Number of children in the home Are you currently employed? Yes No Hours employed per week Are other adults in the home employed? Yes No Select any of the situations below that apply to your family: Free School Lunches Reduced School Lunches Medical Assistance Other… Enter other… Please indicate yearly family income below: 0-$5,000 $5,001-10,000 $10,001-15,000 $15,001-20,000 $20,001-25,000 Other… Enter other… Penn State Altoona’s Office of Continuing Education offers sincere thanks to Investment Savings Bank and local donors who make these scholarships possible. Submit