Please print the application, fill it out, and mail it to KMAC.  The information you provide will be strictly confidential.  An incomplete application will result in a delay for scholarship consideration. Mail completed application to:

                                        Kent Mountain Adventure Center
                                                        PO Box 835
                                                Estes Park, CO. 80517

If you have any questions or need assistance, please call KMAC (970) 586-5990. 

PART 1 - To be completed by parent/guardian.

Participant Name _________________________________________

Address/P.O. Box_________________________________________

City ____________________________________________

State ______________ Zip ________________

Parent/Legal Guardian ____________________________________________

Home Phone (_______)____________

Work Phone (_______)____________

Course ______________________________________________________

Number of People in Family ___________

Family income per month before taxes $___________________

Why do you wish your child to participate on this course?

Special Circumstances:

What agreements or arrangements do you have with your child in relation to this course?

Maximum fee you can pay $______________

I certify that the information on this application is true and correct.  Any false information will disqualify my child from receiving scholarship assistance.

Signature _________________________________________________

Date ____________________________

PART 2 – To be completed by the participant

How are you making this course possible?

Are you earning money for this course?  If so, how?

Why do you wish to participate on this course?

What goals do you hope to achieve from this experience?

Participant Signature ______________________________________________  

Date ______________________