Date:_______________
Name:_______________________________ Name to be called:______________ Sex: M__ F__
E-mail address:__________________________________ AIM Screenname:________________
Address:_______________________________________ Date of Birth:____________________
City:__________________________________ State: _________ Zip Code:_________________
Home Phone:___________________________ cell phone (if applicable): ___________________
Your School:____________________________ Graduation Year: ____________Grade:_______
Do you have any physical issues we should know about?_________________________________
Are you on any special medications?_________________________________________________
Do you have any special dietary requirements?_________________________________________
Parish:________________________________________Denomination:____________________
Parish Address: _________________________City: _______________State:____ Zip:________
Priest’s Name: (please print)________________Priest’s Signature:________________________
Father’s Name:______________________ Address:(if different)__________________________
City:____________________________________ State:_____ Zip Code:___________________
Home Phone:________________________ Work Phone and/or cell phone:__________________
Mother’s Name:______________________ Address:(if different)_________________________
City:___________________________________ State:______ Zip Code:___________________
Home Phone:________________________ Work Phone and/or cell phone:__________________
SPECIAL NOTE: In the event of emergency, I wish to be notified immediately. If I cannot be reached, I give permission for medical care to be administered and I agree to pay all charges not covered by insurance with such treatment.
Parent/Guardian Signature:_____________________________________ Date:______________
A non-refundable deposit of $40.00 must accompany this application. Please make all checks/money orders payable to: “Happening of MA.” The total cost for the weekend is $110.00. Send application and Deposit to: Amanda Surgens, PO Box 732, Bridgewater, MA 02324. My cell phone: 508-272-4879.