Name

Age

Birthday

Address

Name of legal guardian

Phone number

Email address

Emergency contact name

Phone number

Address

Referring agency if applicable

Name of person referring

Contact information

Please advice the domicile of the applicant (ie. foster care, at-home, etc.)

Is the applicant currently attending school? If so, what grade?

Please provide a brief history of the applicant, and why you believe they are a good fit for this program.

Is the applicant currently taking any medications? If so, please list.

If under doctor's care, has the medical doctor reviewed the suitability of the applicant for this program?

Is the applicant suffering from any disabilities that might preclude participating in any activities?

There is partial and full funding available upon assessment of application. Please indicate what you are requesting. There is partial and full funding available upon assessment of application. Please indicate what you are requesting.Full SponsorshipPartial Sponsorship (50% co-pay)I don't need any sponsorship, I agree to pay the full cost of the program

Please explain your sponsorship request, and why your daughter is a good fit for sponsorship.