Civitan Leaders In Freedom Conference (LIF) - Student Application
Piankatank Camp & Conference Center, Hartfield, VA December 6-8, 2019
All application submissions will receive a confirmation letter within 10 days of submitting your information from the Leaders In Freedom Coordinators. Your confirmation letter will require both parent and student signatures and will need to be emailed back to ChesapeakeJrCivitan@gmail.com before any student is considered confirmed.
If you do not receive a confirmation letter, 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
*
-
Area Code
Phone Number
Date of Birth:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender-- students are housed in gender specific dorms.
*
Male
Female
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Parent/Guardian Info & Emergency Contact
Once application is received, 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
*
-
Area Code
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 (please complete)
*
-
Area Code
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.
*
Clubs 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
*
-
Area Code
Phone Number
Date of most recent physical exam
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of most recent tetanus immunization
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Insurance Carrier
*
Policy/Group Number
*
Name of Primary Insured
*
Does student have any medical disorders, allergies or disease wich may affect his/her attendance at this conference?
*
List any food allergies
*
Do you have any special diet 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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Coordination Info
Who invited you to apply to the 2019 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
Should be Empty: