Application Form Name * First Name Last Name Date of birth * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Email * Do you have a Social Security Number? * yes no Name of Parent/Guardian (under 18) First Name Last Name Select Other Father Mother Phone (###) ### #### Email References (3) Name 1 First Name Last Name Email Phone (###) ### #### Name 2 First Name Last Name Email Phone (###) ### #### Name 3 First Name Last Name Email Phone (###) ### #### About you How many years have you been a Seventh-Day Adventist? Why do you want to canvass this summer? Your favorite music groups Earliest Date Available Health information Are you taking any medications? * yes no Do you have any food allergies? * yes no Do you have any medicine allergies? * yes no Are you covered under a health insurance plan? * yes no I understand that basic medical coverage is required to participate in this program. It can be made available at the beginning of the summer for a set cost (for more information contact your canvassing leader) * yes School information Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Your Major Where do you plan to attend school next year? Comments Thank you!