Family Name
Household headed by: Mother & Father Mother Father Grandmother Grandfather Other (please specify)	Monthly income range: *Acceptance is not based on household income range $250-$500 $501-$750 $751-$1000 $1001-$1250 $1251-$1500 $1501-$2000 $2001 and up

Family members applying to attend the retreat/camp

Parent(s) or Legal Guardians	Age	Gender	Relationship to family

Children living in the same household of the above parent(s) or guardian(s)

Children	Age	Gender	Relationship to family

Family mailing address: Please provide a complete address

Address	Apt. #
City	State
Zip
Home phone	Cell
Email address

HIV case manager

Agency

Phone number Ext.

How did you hear about Red Ribbon Trails?

Please tell us why you are interested in attending Red Ribbon Trails camp.

Do you plan to attend another camp this year? yes no

Do you have people to talk to about your status? yes no

Have you ever had an open case with DCFS? yes no

If yes, is your case still open?  yes no

Are you currently receiving TANF? yes no

If yes, please include your case number: 
(This information is required for funding purposes.)