*First Name: *Last Name:

*Address:

*City: *State: *Zip:

*Phone: Cell: Work:

*Email Address:

*Age: Gender: Gender Male Female

Typing your name and date below means you agree not to smoke on camp grounds. It will serve as an electronic signature putting you into an agreement with Full Life Ahead Foundation.

Name: Date :

Please complete the following:

Your interest in individuals who have a disAbility:

Do you have a disAbility? Yes No

Do you use a manual or power wheelchair? Yes No

Service provider or a teacher for individuals with disAbilities? Yes No

Agency or school name:

Special Talents:

Past experience:

Areas of interest:
Children   Teen   Single Parents  

Lead Programs Crafts   Outdoor Activities  

Kitchen Clean-Up Serve Meals   Support Help

What day will you arrive? Friday Saturday Sunday Arrival time: 1 2 3 4 5 6 7 8 9 10 11 12 am pm

What day will you depart? Friday Saturday Sunday Departure time: 1 2 3 4 5 6 7 8 9 10 11 12 am pm

Indicate room mate choice (no more than 5 in a cabin)