1. Semester Available (check all that apply)

  Fall     Winter     Spring     Summer     Not sure

2. Last Name

First Name

  Male     Female

3. Street Address

Apt #

City

State -- Select State -- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code

How long at this address (years)?

Previous address if less than 5 Years:

4. Home Phone

Cell Phone

E-Mail

5. Age

Driver's License #

SS#

6. Are you currently enrolled in high school?

  Yes     No

Anticipated grade level in 2016-17

7. Name of School

Address

City

State -- Select State -- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code

8. Parent/Guardian

Relationship

Phone No.

9a. Have you ever volunteered for a school and/or after-school program?

  Yes     No

If yes, describe:

9b. How long were you involved in the organization mentioned in #9a?

years

months

10. Do you speak any other languages other any English?

  Yes     No

If yes, please list:

11. Availability (check all that apply):

  Mon.     Tue.     Wed.     Thu.     Fri.     Sat.     Not sure

12. Please list any relevant experiences or skills:

13. Why do you think the Cresthaven Futures Program is right for you?

14. What do you hope to learn through this experience?

15. Please list at least two personal references that have known you longer than one (1) year, excluding relatives:

Applicant's Statement & Parental Consent

Please read carefully before signing: The information contained in this application is correct to the best of my knowledge. I, (applicant's name) authorize any references listed in this application to give you information they may have regarding my character and fitness for volunteer work with students, and I release all such references from liability for any damage that may result from furnishing such evaluations to you. I, (parent's name) hereby issue consent for my child to apply for and participate in the Cresthaven Futures Program and all required program activities, and I endorse the aforementioned statement signed by said applicant.

Photograph and video release: I hereby grant Cresthaven Academy Charter School and Cresthaven Academy Foundation permission to the rights of my child's image, likeness and sound of voice as recorded on audio or videotape without payment or any other consideration. I understand that his/her image may be edited, copied, exhibited, published or distributed and waive the right to inspect or approve the finished product wherein their likeness appears. I also understand that this material may be used in any school or foundation property, promotion or website.