Encounter the Gospel of Life

Individual Application

Part I: To apply for Encounter 2012 please complete the following form. You must hit the "Register for Encounter 2012" in order to complete PART I of this registration.

Part II: You will then be presented with a printable PDF to be signed by your parents/guardians and a medical form to be signed by your doctor, both of which must be returned to your group leader to complete registration.

* Fields marked with an asterisk are required.

Participant Information

First Name *

Last Name *

Gender *

T-Shirt Size *

Birthday *

Parish or Group *

School (in fall 2012) *
If you are not in school, please write "none" in the box above.

School (in fall 2012) *

Special Needs *
If none, please write "none" in the box above.

Participant Contact Information

Home Phone *

Participant's Cell Phone *

Participant's Email Address *

Address *

City *

State *

Zip Code *

Past Experiences

Have you been to Encounter before? * Yes
No

What are your experience, gifts, skills, language, music, etc? *

Please indicate what type of site you are open to. * Please note that there are no guarantees on site placement! Children/Youth/Families
Elderly/Disabled
Soup Kitchens/Shelters
Clean-up/Fix-up
Environmental
All

Parents/Guardians & Emergency Contacts

Parent / Guardian One OR Spouse

Name *

Address *

City *

State *

Zip Code *

Phone (AM) *

Phone (PM) *

Cell Phone

Email Address *

Parent / Guardian Two

Name

Address

City

State

Zip Code

Phone (AM)

Phone (PM)

Cell Phone

Email Address

Emergency Contact

Name *

Phone (am) *

Phone (pm) *

Cell Phone *

Relationship *

Insurance & Medical Information

Insurance * I am covered by hospitalization and medical insurance
I do not have medical coverage and assume responsibility for the cost

Medication (dosage & frequency), allergies, illnesses, etc. * If participant is on medication of any kind (even over the counter medication), information must be indicated here and medication must be with participant for the week without exception!

If none, please write "none" in the box above.

Medication I do not want my child given any medication

Dietary Restrictions *
If none, please write "none" in the box above.