Tanzania Service Learning Application InterConnections 21

First name of student as it appears on passport *

Middle name of student as it appears on passport *

Last name of student as it appears on passport *

Age (as of July 28, 2014) *

Date of Birth *

Sex (m/f) *

Height

Weight

Email *

Home Phone *

Cell Phone *

Year in school ('13 - '14) *

9101112

Name of school *

Jackson Hole High SchoolJourneys SchoolJackson Hole Community SchoolOther

Please list prior summer camps or programs

Extra-curricular activities in which you participate

Other volunteer or leadership positions:

First Name of Primary Parent *

Last Name of Primary Parent *

Parent's Email *

Parent's mailing address *

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Cell Phone *

Work Phone *

Home Phone *

Parent's place of employment *

First Name of Secondary Parent *If you do not wish to enter a secondary parent, Please put n/a in the following fields.

Last Name of Secondary Parent *

Parent's Email

Parent's Address

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Parent's place of employment

Cell Phone

Work Phone

Home Phone

With whom does the applicant live? *

PrimarySecondaryBoth

Who should receive all mailings? *

PrimarySecondaryBoth

Attach a statement explaining why you would like to join the Tanzania Service Learning Project and what you feel you can contribute to it. 500 word maximum

Upload essay *.docx, .doc and .pdf files only please

Contact evan@ic21.org with questions

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