Date: ____/______/______

PROVISION 47
APPLICATION
Parent/Guardian (1) Information:
Name: _________________________

Phone: _______________________

DOB_____/______/______ Address: _______________________________________ City/ST _________

Zip __________
Parent/Guardian (2) Information:
Name: _________________________

Phone: _______________________

DOB_____/______/______ Address: _______________________________________ City/ST _________

Zip __________
Teen Information:
Teen (1) Information:
Name: _________________________

Phone: _______________________

DOB_____/______/______ Address: _______________________________________ City/ST _________

Zip __________
Same as Parent/Guardian
Teen (2) Information:
Name: _________________________

Phone: _______________________

DOB_____/______/______ Address: _______________________________________ City/ST _________

Zip __________
Same as Parent/Guardian

 Would you be interested in sponsoring a child?

Are you a scholarship participant?

What interest you most about the program?

_________________________________________________________________________________________
_________________________________________________________________________________________
_____________________________________________________________________________
Do you or someone you know own a business?
If: Someone you know? Who? Can we contact them? * We might contact them to see if
their interested in coming to talk to the students about their business.
_________________________________________________________________________________________
_________________________________________________________________________________________
_____________________________________________________________________________
Questions or Comments?
_________________________________________________________________________________________
_________________________________________________________________________________________
_____________________________________________________________________________
Would you be interested in donating to the youth fund? This money would go towards
the student(s) funds to start their business.
Yes / No
Is it okay if we call you?
Yes / No
3 things the teen likes:
1. _________________________
2. _________________________
3. _________________________

Emergency Contact List:

Contact 1:
Name: _________________________

Phone: _______________________

DOB_____/______/______ Address: _______________________________________ City/ST _________

Zip __________
Contact 2:
Name: _________________________

Phone: _______________________

DOB_____/______/______ Address: _______________________________________ City/ST _________

Zip __________
Contact 3:
Name: _________________________

Phone: _______________________

DOB_____/______/______ Address: _______________________________________ City/ST _________

Zip __________

Allergies:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________

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@ProVision 47- Circle City Computers
By signing this form I attest that all information is true to the best of my knowledge. I
certify that I will not try to obtain, retain, copy, duplicate the course, course material,
and learning experience in any kind of way. I understand that there are no refunds.
Print ___________________________________

Date _______________

Sign ___________________________________

Date _______________