CSM FINANCIAL ASSISTANCE APPLICATION

Parent or Guardian's Name

First Name

Last Name

Today's date

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

County of residency

Phone number

(###)

###

####

Email

Age

Marital Status

Married

Single

Virginia Resident

Yes

No

Do you regularly attend Cornerstone?

Yes

No

Name of Student(s) Attending Camp

Amount Requested

$

Amount you are able to contribute

$

Reason for need

Signature

Please type name/date below to submit electronic signature: