Ladies of Favor, Inc. Application Form

I. General Information
Date of Application*

MonthDayYear
Student Full Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Age*
Grade*
T-shirt Size*
Present Address*

Street Address

Street Address Line 2

CityState

Zip Code
Parent Full Name*

First NameMiddle NameLast Name
Relationship*
Mobile Number*
E-mail*
Parent Full Name

First NameMiddle NameLast Name
Relationship
Mobile Number
E-mail
example@example.com
Person to contact in case of emergency:*
Parent/Guardian
Relationship*
ex. Father, Mother, etc.
Present Address*

Street Address

Street Address Line 2

CityState

Zip Code
Mobile Number*
Student Resides With?*
II. Educational Information
School Attended:*
Grade*
Student Academic Performance:*

Superior (A+)Above Average (A-B)Average (B-C)Below Average ( C-D)Poor (Failing)
Has Student Been Diagnosed with any Psychological, Mental, Emotional, and/or Behavioral Diagnosis? (If yes, please provide details.):*
Describe Students Behavior in School:*
List any extracurricular activities youth is involved in.:*
III. Medical Information
Describe below all physical health conditions or illnesses which may limit the child's participation in programs or activities. ):*
Please List Any Medications Prescribed*
Is your daughter currently seeing a counselor or therapist?*

YesNo
Please List Name and Number of Provider
IV. STATEMENT OF CHARACTER:
Please state why your daughter should be accepted into Ladies of Favor, Inc. Describe your daughters' attributes, achievements, and any additional information that will speak to her character and development. *
What are your expectations regarding your daughter participating in Ladies of Favor, Inc.?*
Agreement & Signature:
I agree to allow Ladies of Favor, Inc. to process personal information contained in this application for any purposes connected to accepting my child into the organization.

I certify that, to the best of my belief, the information I have provided is complete and true.
Name of Applicant

First NameLast Name
Signature

Clear
Date

daymonthyear
Should be Empty:

I. General Information

II. Educational Information

III. Medical Information

IV. STATEMENT OF CHARACTER:

Agreement & Signature: