CUESA's Foodwise Kids Scholarship Registration Form

This year, CUESA's Foodwise Kids is partnering with Bay Leaf Kitchen to offer two sessions of camp at the Ferry Building and Eatwell Farm. CUESA raised funds to provide scholarships for past Foodwise Kids participants to attend a one-week camp in June 2015. 

 Please submit a Foodwise Kids scholarship request form by April 1, 2015 and it will be reviewed by the Scholarship Committee. 

To register for camp, fill out the information below. If you have any problems completing your registration, please email elianna@bayleafkitchen.org or call Elianna at 650-731-2428.

If you have questions regarding your Foodwise Kids Scholarship please email Theresa at theresa@cuesa.org. 

Please allow for at least 15 minutes for the registration process.

Student Information
Student's Full Name *
Student's Full Name
Date of Birth
Date of Birth
(Be sure to match the date format with two digits for date and month)
Gender *
Grade *
Entering 2015 School Year
Parent/Guardian Information
At least one set of parent/guardian information is required.
Parent 1
required
Parent 1 Name *
Parent 1 Name
Parent 1 Address
Parent 1 Address
Parent 1 Home Phone *
Parent 1 Home Phone
Parent 1 Cell Phone *
Parent 1 Cell Phone
Parent 2
optional
Parent 2 Name
Parent 2 Name
Parent 2 Address
Parent 2 Address
If Different than Parent 1
Parent 2 Home Phone
Parent 2 Home Phone
Parent 2 Cell Phone
Parent 2 Cell Phone
Pick-up Authorization
OPTIONAL
Name
Name
Home Phone
Home Phone
Cell Phone
Cell Phone
Emergency Contact Information
specify at least one person other than the parent
Emergency Contact 1
required
Name
Name
Home Phone
Home Phone
Cell Phone
Cell Phone
Emergency Contact 2
optional
Name
Name
Home Phone
Home Phone
Cell Phone
Cell Phone
Health and Medical Information
Physician Name
Physician Name
Physician Phone
Physician Phone
optional
Dentist Name
Dentist Name
optional
Dentist Phone
Dentist Phone
If yes, please list them here.
If yes, please list them here.
If yes, please describe them here.
Special Requests
optional
If so list name(s) here.
SUMMER 2015 CAMP SESSIONS
Please select the camp session(s) your child will be attending. *
Pre-camp survey
Household Income
Select one.
Race/Ethnicity
Select one.
Where does your household purchase food from? *
Select all that apply.
Select one.
Select one.
Select one.
Payment Information
To pay for camp, I am: *
select one
Financial Aid - Please complete all questions to be considered for financial aid
Our goal is to make our classes available to everyone. We offer full and partial financial assistance based on need. Please submit the below supplemental application to be considered. Financial Assistance applications are encouraged to apply as early as possible. Class spots are reserved on a first come first served basis and are confirmed with a $50 processing fee to hold the date.
Describe any changes in family or economic circumstances over the past year that support your request for financial assistance this year. Please indicate the date, the estimated cost of this change and which parent (one or both) was affected.
Estimated Combine Annual Gross Income for 2014
Select one.
$
Form Submission Details
please review and check the following
Terms
CANCELLATIONS -- Our refund policy is designed to discourage last minute cancellations and to help families on the waiting list. The fee is refundable minus $50.00 for requests received in writing via e-mail to elianna@bayleafkitchen.org before April 1st, 2015. After April 1st, there is no refund unless the space can be filled by another student. During classes there is no refund for student illness, missed days, vacations, or dismissal from the program. Classes may be subject to change.
I have read and completed all sections of this application and verify that the information provided is correct.
I have read and completed all sections of this application and verify that the information provided is correct.