Sponsors

Plainfield PAL's Youth Exposure
"Expanding Minds & Horizons"

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Application

Please complete the form below and submit upon completion. Please note that there is an $50.00 annual application fee (non refundable) which can be hand delivered after acceptance. The red asterisk * denotes required fields.

First Name: *
Last Name: *
Address Street 1: *
Address Street 2:
City: *
State: *
Zip Code: *	(5 digits)
Date of birth: *
Gender: *
School: *
Grade: *
Shirt size:
Site: *	(Atlantic City or Plainfield)
Parent/Guardian *
Relationship (to applicant): *
Address (if different from applicant):
State:
City:
Zip code:
Daytime Phone: *	(ex.123-456-7890)
Cell Phone:
Evening Phone:
Email:
Parent/Guardian 2:
Relationship (to applicant):
Address (if different from applicant):
City:
State:
Zip code:
Daytime Phone:
Cell phone:
Evening Phone:
Email:
Physician's Name:
Physician's Phone:
Allergies (please describe):
Comments:	Enter comments here!

Click Here: Youth Summit