Adult Application

*Student's Full Name:

PERSONAL INFORMATION

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*Zip Code:

*State:

*Age:

*Birth Date

*Cell Number or Home Number:

EMERGENCY INFORMATION

IN CASE OF INJURY, ILLNESS, OR DISASTER, who may we contact:

*Gender:

*1st Contact Full Name:

*2nd Contact:

*1st Contact Relationship:

*2nd Contact Relationship:

*Cell Phone1:

*Cell Phone2:

*Physician

*Health Plan:

*Physician's Address/City:

*Physician's Phone:

SCHOOL & OTHER INFORMATION:

*Are you currently enrolled in college courses?

*Marital Status?

*What is your income level?

IN CASE OF AN EMERGENCY, I GIVE MY CONSENT TO HAVE SUCH MEDICAL ATTENTION PROVIDED AS THOUGHT NECESSARY BY A NURSE, PHYSICIAN, PARAMEDIC, OR HOSPITAL IN CHARGE.

*Please provide email address that you open daily. Email:

Registration Fee

There is a one-time registration fee of $25/student which covers the cost of the student's program T-shirt and program binder. Students will receive lots of information during the course of the program. The program services are at "no cost," based upon fundraising participation. Each student will need to raise $250.

Please select your student's size below:

Number of T-shirts Ordered:

You may either mail your registration to be received by September 29th, pay online to secure your youth's space.

To mail:

Trinity's Learning Resource Center

12725 W. Indian School Road, Suite E-101

Avondale, AZ 85392

To pay online through Paypal.com (a secured payment processing): There is a wire transfer fee automatically charged by Paypal.com for each item. Please be sure to accurately calculate your total and note in the box below before making payment.

Registration fee total will be $26.06 (including $1.05 wire transfer fee/per T-shirt). Fundraising Donation will be $250.80 per person (including a $7.80 wire transfer fee). To make Fundraising Donation (see below). You can receive a tax deduction for a charitable contribution.

1) Please add up your total and note here:

2) Place order/make donation below:

For Registration & T-shirt orders:

For Fundraising Donations:

Important Note: Space is not guaranteed without online registration and registration fee paid. Please complete the online application if you have not already done so, and make payment above, or mail in your registration fee for each student enrolling in order to secure their space.

Those who do not pay registration fee at time of online application (or by Orientation), will be placed on a waiting list.

Participation Authorization

A Desire to Succeed

Students must have the desire to be successful and be committed in every way possible to reach their life purpose, potential and goals in life. Student agrees to be cooperative, open, creative and will always be willing to participate in program activities. They commit to ask for help in order to obtain my goals. They will do everything to help in the success of their fellow classmates and the program. They agree to abide by the Learning Center’s rules and regulations.

Prayer

As apart of our program, we pray before and at the end of each class session. We believe that no man, family, or organization can be successful without the help [and aid] of God, drawing upon His Wisdom, strength, and insight. Therefore, we seek and ask the Lord’s blessing upon the class session and upon each student and family. We pray and intercede for individuals, families, and situations that students are concerned about so that all may receive God’s power to prosper and have good success. Although we pray, we are sensitive to and respect others who may not. No child will be made to feel they have to pray.

Approved Program Curriculum

Student’s curriculum and reading will include motivational and inspirational material that will help enhance self-esteem, help them to understand their purpose and potential, and help them to reach their life goals. This information contains biblical references, principles, and other quotes from scholars who are successful in different fields of life.

Photograph Authorization

Trinity will take photographs of you strictly for program promotional purposes (newsletter, press releases, etc.).

Fundraising Agreement

As a Nonprofit organization, the Learning Center depends not only upon the financial contributions of the public and private sectors, but is also required to host fundraising programs of its own. Throughout the year, we will conducting fundraising activities such as Little Caesar's pizza & cookie dough sales, a car wash, a family fun nighty (dinner & silent auction), etc. Participation is required for each student enrolled. As a student of age, you accept full responsibility to complete the fundraising efforts, and to make sure that all monies are turned into the Learning Center on time. There are minimums required for each event. Through Fundraising and sponsorship requests, each participant must raise a minimum of $250. (This is to cover the costs for program materials, award jackets, incentives, awards, and graduation). Parents/students are responsible to sell all items required for each fundraiser, or become financially responsible (Example: You will be given 8 car wash tickets to sale at $5.00/donation each. You must sell them or become financially responsible for what was not sold.) This program becomes “no cost” if students participate in fundraising programs (selling the minimum required) as noted herein. All monies are due on the due dates as noted on the Fundraiser Instructions. If monies are not turned in as instructed, you will be billed for the amount due, and payment is due upon receipt. For this reason, we strongly encourage you to actively participate in all fundraising activities before the due date. Funds raised benefit your life skills enrichment program and graduation, which is preparing you and the youth of our community for successful living.

Program Fundraising Options:

- Participate in all fundraisers and raise $250/per person, or

- You can request and obtain sponsorships from friends, family, co-workers, other individuals,

and businesses, etc. To print sponsorship forms to provide your potential sponsors, click on the links

below. All Sponsors are publicly recognized at our graduation banquet.

Please select (one):

Enrollment is conditioned upon agreement and authorization of the above. Complete all fields below:

* I

agree to participate in the program and will

fulfill the fundraising requirements. This completed online application indicates your approval and commitment.

HEALTH CONDITION/MEDICATIONS (Please specify below):