Community Service

Student Personal Details

Name*

FirstLast

Date of Birth -mm/dd/yyyy*

Your Gender*

Male
Female

Location

High School*

What is your current grade in school?*

American Home Address*

Street AddressAddress Line 2CityStateZip Code

Student's Email*

Student's Cell Phone*

Host Family's or Guardian's name*

FirstLast

Host Family's or Guardian's Phone*

Which event are you reserving?*

Terms and conditions: Hotel Stay $ 75 per night (shared room) for 4 nights, Transportation $35 per day for 5 days, Consultant $100 for the entire trip. I agree to the total fee of $550. *

I agree to the total fee of $550
I understand that I am responsible for flight charges (if applicable)
I agree to pay the Community Service Trip fee before April 8, 2012

Family Information

Father's Name

FirstLast

Father's Email

Father's Phone

Mother's Name

FirstLast

Mother's Email

Mother's Phone

Questions or Comments?

Medical History

Medical Insurance Company*

Insurance Policy number*

Do you take any medications, vitamins or herbal remedies?*

Yes
No

If "Yes" describe what you take and how often:

Do you have any allergies or chronic illnesses?*

Yes
No

Do you have any dietary restrictions?

If "Yes" list allergies or chronic illnesses:

Referral Section

Application completed by:

FirstLast

Relationship to student

How did you hear about the tour?*

i.e. internet, advertisement, school, friend. If it was a person write down who it was.

Questions or Comments?

Email

Email for confirmation email

Community Service

Building A Home of Hope with Habitat For Humanity

Community Service Request Page