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.