Mississippi Valley FCA

2025 Pella Summer Camps Scholarship Request Form

Please complete the form below to request an Mississippi FCA Camp Scholarship. Scholarships will be awarded based on the applicant's need and in the order they are received.

Name: (First, Last)

Gender

Male

Female

Date of Birth

Street Address

City

State

Zip

School

Grade (Upcoming School Year)

Church Name

Parent/Guardian Name(s)

Student's Email

Parents Email

Parents Phone Number

Student Phone Number

Have you received an FCA Camp Scholarship before

Yes

If Yes How Much Was The Amount

Parents combined gross income (check one)

Under $20,000

$20,000 - $35,000

$35,000 - $50,000

$50,000 - $75,000

Above $75,000

Is this a dual income home

Yes

Is this a single parent home

Yes

Total number of children in the home?

Camper's comments on desire to attend an FCA Summer Camp:

Parent/Guardian's comments regarding camper's interest in attending a FCA Summer Camp and request for camp scholarship funds:

Todays Date

Preferred Sport

Thank you for submitting your request for a FCA Camp Scholarship

The Mississippi Valley FCA office will contact you with further details to assist you with camp registration.

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Contact Info

P.O. Box 124

Eldridge, IA 52748

(563) 210-4816

lrunte@fca.org

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