Magdalen College Summer Youth Program

Please fill out all sections. All information will be kept strictly confidential.

Personal Information

Name

Last

First

Middle

Home Address

Street

City

State

Zip

Date of Birth

Place of Birth

Date of Baptism

Date of Confirmation

Phone

E-mail Address

High School Attending

Year of Graduation

Number of Brothers

Number of Sisters

Father

Father's Name

Occupation

Work or Cell Phone

If Deceased, Date of Death

Mother

Mother's Name

Occupation

Work or Cell Phone

If Deceased, Date of Death

If your parents are not living, or you are not living with them, who is your legal guardian?

Name

Address

Do you have any medical condition or handicap (such as asthma, allergies, diabetes, etc.) that will prohibit certain activities?

Are you currently taking any medication?

How did you learn about the Summer Youth Program?

List community, religious, and/or extra-curricular activities in which you have participated:

Write a short essay (3–4 paragraphs) explaining why you wish to attend the Program.

Please indicate the Session(s) you want to attend (dates can be found on the inside cover):

I hereby certify that all information on this application, and all information submitted as part of this application, is complete and accurate.