Date of Application:

Student Name:

Parent/Guardian's Name:

Address:

Home Phone No.:

Parent Work/Other No.:

Parent Cell No.:

Parent Email Address (Optional):

Date of Birth:

Gender: Male    Female

Grade completed at the end of the school year:

Program(s) you are interested in: Art Camp Leadership Camp Green Team Biz Camp STEMS Career Camp

T Shirt Size: Small Medium Large XL 2XL 3XL

Have you participated in a Franklin Center or Aliquippa Alliance Impact program before?

If "yes", then what program?

Application Questions

(Write N/A if these questions do not apply to you...DO NOT LEAVE THIS AREA BLANK!!!)

List any jobs, internships, and/or volunteer experience in which you have participated.

List any hobbies and/or extra-curricular activities in which you are involved.

If you could start the business of your dreams, what would it be?

Why are you interested in this program (must be completed by student)?

List one reference who knows you well and would give you a recommendation (a teacher, minister, family friend). References cannot be family members.

Name:

Address:

Phone No.:

By signing below, I give permission for to participate in the Aliquippa Impact/Franklin Center summer youth program that we have selected.

In doing so, I also grant permission to the Franklin Center of Beaver County (formerly AAUD), Aliquippa Impact Ministries, the National Foundation for Teaching Entrepreneurship, and the Community College of Beaver County to use my child's likeness and that of my child's work in any promotional campaign, in any media, i.e. print, Interactive CD, World Wide Web, etc. I also understand that no party will sell or distribute any copy of my child's likeness to any other party.

I also certify that the information provided is true and correct, and complete to the best of my knowledge and belief. I am also aware that the information I have provided is subject to review and verification. I may have to provide information to support this application. I allow release of this information to my child's school staff if needed for verification purposes.

Student Signature:    _________________________________________

Parent/Guardian Signature: ___________________________________