Applicant's Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Permanent Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone Number

Country

(###)

###

####

Cell Phone Number *

Country

(###)

###

####

Primary Parent or Guardian Name *

First Name

Last Name

Primary Parent or Guardian Phone Number *

if different than above

(###)

###

####

Parent or Guardian Name

First Name

Last Name

I will attend: *

Winter Gathering - (January in Brown Co.)

Visitors' Day - (During Camp in May)

Address of Last High School *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Are you receiving any other scholarships? *

Yes, I have received or am expecting to receive additional scholarships.

No, I have not applied for any additional scholarships.

Unsure, I have applied for other scholarships (or intend to apply for other scholarships) but have not received a response

Address of Higher Education Institute Pursued: *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Academic Advisor's Name: *

First Name

Last Name

Have you already been accepted? *

Yes

Not Yet

Expected Start Date *

MM

DD

YYYY

Expected Graduation Date *

MM

DD

YYYY

Have you submitted ALL documents in the description below to valerie@hoosierburncamp.org? *

A copy of your most recent semester's transcript, Two letters of recommendation from teachers, advisors, or adults (non-family members), & A one-page essay outlining your career and education goals along with an explanation on how Hoosier Burn Camp has made an impact or difference in your life

Yes, I have been proactive and sent my supplemental materials to markkoopman@hoosierburncamp.org

Not yet, but I will send these materials before the application due date