Pike County Federation of Sportsmen's Clubs
2007 Youth Conservation School
Application Form
Please print out this form and complete all the requested information to the best of your ability. Applications must be returned to: THE PIKE COUNTY FEDERATION OF SPORTSMEN'S CLUBS, P.O. BOX 681, MILFORD, PA 18337. Do not e-mail the application. E-mail submissions will be refused. A check for the student fee of $50.00 must accompany the application. All checks must be made payable to THE PIKE COUNTY FEDERATION OF SPORTSMEN'S CLUBS. The application, check, and any accompanying support material (eg. letters of recommendation) should be received by the Federation no later than June 30, 2007.
Name ___________________________________ Date of Birth ______________
Address _________________________________ Boy _________ Girl ________
City ____________________________________ State ________ Zip _________
Area Code & Telephone Number - Day ( ___ ) ______ Evening ( ___ ) ________
Applicant's Social Security Number (required) ____________________________
School District ________________________ Grade Level 2006-2007 __________
Favorite Subjects ____________________________________________________
Extracurricular Activities, Honors, and Awards ___________________________
______________________________________________________________________
______________________________________________________________________
The main purpose of the Conservation School is EDUCATION. In a short essay of no less than 100 words, please state your reasons for wanting to attend the school AND how you will put the knowledge obtained to good use. Please use an additional 8 1/2 x 11 sheet of paper and attach it to the application. Please write legibly.
Hobbies _________________________________________________________________
Please list any outdoor interests you have or special conservation programs that you may have participated in:
_________________________________________________________________________
_________________________________________________________________________
List at least two people that can be contacted for a recommendation. (It would be extremely helpful to the selection committee if at least one letter of recommendation accompanies the application. However, please do not hold the application past the deadline to await the letter of recommendation.)
Name _______________________________ Telephone ( ___ ) _______________
Address___________________________________________________________________
City __________________________________ State _______ Zip _____________
Name ________________________________ Telephone ( __ ) _______________
Address___________________________________________________________________
City _________________________________ State ________ Zip _____________
The following must be completed by the applicant's parent or guardian:
_______________________________ has my permission to take part in the Pike County Federation of Sportsmen's Clubs Youth Conservation School at Lacawac Sanctuary and to travel to other facilities and locations for educational programs. The signing of this application releases the Pike County Federation of Sportsmen's Clubs Inc. and the Lacawac Sanctuary Foundation Inc. and any participating organizations, agencies, and volunteers from all claims for accidents or injuries incurred by the applicant in the normal course of instruction. A medical permission form will be sent to each selected applicant for completion.
____________________________________
signature of parent / guardian
______________
date
( ______ ) ______________
telephone number
Parent / guardian's e-mail address : _____________________________________
