Breakaway Scholarship Request Form 2026

Your name *

Email address *

Family Information

Please list child(ren)s name and grade(s) they will be entering Fall 2026. *

If you're filling out a form for multiple children, please write one per line

Relationship to scholarship request child(ren) *

Address *

Phone number

Email Address *

Have you attended any church in the last 12 months? *

Yes

If so, which church?

Are you volunteering to help at Breakaway?

Is this your first time attending Breakaway? *

Yes

In order to keep costs down and Scholarship as many campers as we can, we do ask families to contribute to camp costs.

Please indicate how much you can contribute (per child) in the space provided *

min: 0 / max: 60

I can pay $___________ per child

Please indicate any additional information to help our Committee on their decision. *

Please share with us your need. Please know we are praying for you and your family always. Blessings.

A copy of your responses will be sent to your email address.