Name ____________________________________ __________________________
Last, First, M.I. Preferred name for name tag
Parents' Names _____________________________________________________
Home Address _______________________________________________________
Street, City, State, Zip Code
Home Phone __________________ Date of Birth _____________ Sex M F
High School ___________________________________________ Year __________
College _______________________________________________ Year __________
Employment Full Time - Part Time
Current Address and Phone if other than above.
_____________________________________________________________________________________
If you are currently active in church, please indicate what church,
_____________________________________________________________________________________
Church City State
If above is blank, what is your religious background?
Interests:(Sports, Clubs, Organizations, School Activities, etc.)
_____________________________________________________________________________________
Do you play a musical instrument? Y N
Have you had training in art? Y N
List any medical conditions that the team members should be aware of:
_____________________________________________________________________________________
PLEASE NOTE: In a short letter to accompany this form, please tell us about yourself, covering items as:
a. What you plan to do after graduation.
b. What you consider to be the principle problems facing youth.
c. What particular worries you personally face today.
d. Why you are going on this weekend.
e. Please include anything else you wish to note about yourself.
THIS LETTER MUST ACCOMPANY THIS FORM. We will attempt to make groupings on the basis of needs and interests.
"I understand that an offering of $95.00 is suggested for this weekend."
Signature _____________________________________ Date ________________
More information will be sent after receipt of application concerning arrangements for the weekend and what to bring.