Civitan Leaders In Freedom Conference (LIF) - Student Application
Piankatank Camp & Conference Center, Hartfield, VA December 3-5, 2021
Please complete the following LIF Student Application in it's entirety for consideration and to be matched with a fully-paid sponsorship. All applicants will receive a notification email within 10 days.
If you do not receive a notification email, please contact ChesapeakeJrCivitan@gmail.com.
Student Info
All fields are required
Name
*
First Name
Last Name
Preferred Name:
Nickname or preferred name
Email
*
Confirmation Email
confirm email
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone Number
*
Date of Birth:
*
-
Month
-
Day
Year
Date
Gender-- students are housed in gender specific dorms.
*
Male
Female
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Parent/Guardian Info & Emergency Contact
Once student is approved and matched with a paid sponsorship, a confirmation letter will be emailed to student and parent for signatures.
Parent/Guardian
*
First Name
Last Name
Email
*
Confirmation Email
confirm email
Address, if different than student's address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone Number
*
Do we have your (Parent/guardain) permission to photograph or video your student during conference activities which may be used for promotional use to include social media?
*
Yes
No
Emergency Contact, please complete even if it is the same parent listed above.
*
First Name
Last Name
Emergency Phone Number
*
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School Info
Name of School
*
School Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Your Grade
*
10th
11th
12th
Are you a member of Junior Civitan? if yes, please indicate your Club's Name.
*
Other Clubs & Associations you belong to:
*
Leadership Positions:
*
Other interests:
*
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Medical Information
Completed student medical Information and release form is a requirement of attending the conference. This information will be included on the confirmation form for signature. No student will be accepted without this information.
Physician's Name
*
First Name
Last Name
Physician's Phone Number
*
Date of most recent physical exam
*
-
Month
-
Day
Year
Date
Date of most recent tetanus immunization
*
-
Month
-
Day
Year
Date
COVID Vaccine Status
*
Student is/will be fully vaccinated with a CDC/WHO approved 2-dose series COVID vaccine prior to 11/18/2021 and present proof as requested.
Student is/will not be vaccinated and will take COVID test within 72 hours from departure and present results as requested and prior to boarding bus.
Insurance Carrier
*
Policy/Group Number
*
Name of Primary Insured
*
Does student have any medical conditions, allergies or disease which may affect his/her attendance at this conference?
*
List any food allergies
*
Do you have any special diet needs or concerns?
*
List any medication allergies
*
Medications currently taken
*
Will the student need to take any prescribed medication while at the conference?
*
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COVID LIF Protocols
Our current COVID protocols can be found on our site at https://adobe.ly/3Dluqoh. (Subject to change, based on CDC requirements, Federal and/or State regulations)
All attendees and chaperones must present legitimate proof they are fully vaccinated against COVID-19 (second/last shot must be no later than Nov 18), or must present proof of a negative COVID-19 test taken no earlier than Nov 30.
*
Agree
All attendees and chaperones will be required to have their temperature taken every day, (and throughout the day as deemed necessary) to enter the bus, enter the camp, enter and participate in all LIF activities.
*
Agree
All attendees and chaperones must agree to wear masks covering nose and mouth, while on the bus and during all indoor activities, with the exception of eating, sleeping, showering.
*
Agree
All attendees and their parent/guardian must read and agree to the COVID LIF Protocols, on the LIF Site. All terms are subject to change. Please refer back fequently. https://adobe.ly/3Dluqoh
*
I have read and agree to the COVID LIF Policy and understand it is subject to change.
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Coordination Info
Who invited you to apply to the 2021 Leaders In Freedom Conference?
*
Do you know the name of the Civitan Club who will be sponsoring you?
*
Which bus stop is the most convenient for you?
*
MARYLAND: Frederick -- McDonald's Restaurant, 423 S. Jefferson St.
MARYLAND Greenbelt -- Shell Gas Station, 5707 Cherrywood Lane (BEHIND Beltway Plaza Mall)
MARYLAND: Hagerstown -- Golden Coral Restaurant, 17635 Valley Mall Road
VIRGINIA: Bedford -- McDonald’s Restaurant, 1128 E Lynchburg Salem Turnpike
VIRGINIA: Lanexa -- 7-11 Store, 14981 Eltham Road (exit 220, I-64 onto Rt. 33)
VIRGINIA: Mechanicsville -- McDonald's (I-295/Rt.301), 9145 Chamberlayne Ave.
VIRGINIA: Newport News -- McDonald’s Restaurant, 652 J. Clyde Morris Blvd.,
VIRGINIA: Springfield -- American Legion Post 176, 6520 Amherst Avenue
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Understanding:
By clicking 'accept' below, I confirm that I understand that I am not a confirmed participant until I have sent back the parent and student signed confirmation letters and received an email stating that I have been confirmed and extended a fully-paid sponsorship. If I have any questions, I will contact ChesapeakeJrCivitan@gmail.com
I accept and understand the above statement.
*
Yes
No
Submit
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