Ready for a different kind of spring break?

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2012

Please complete the following form and payment information.

A $50 deposit is required for registration. The remainder of the payment ($100) will be collected one week before your trip. Scholarship recipients will be reimbursed upon site arrival.

First Name ■

Last Name ■

Gender ■

Female
Male

Age ■

Year in school ■

First

Second

Third

Fourth

Fifth

Other

I am not currently a student.

School/Organization ■

Major/Minor ■

E-Mail Address ■

Phone Number ■

Emergency Contact Info (Name, Relationship, Phone numbers, Address) ■

What are the dates of your 2012 spring break? ■

Any dietary, medical, or other requirements? ■

Are you willing to recruit friends for this trip?

Yes
No

Please list any leadership skills and experiences that will contribute to your participation in the health survey. ■

Why are you interested in participating in the community health survey? ■

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Ready for a different kind of spring break?

2012

Please complete the following form and payment information.