Onething Project Application Date__________________
Name__________________________________ DOB______________ Gender: M / F
Home Phone________________________ Cell _______________________________
Email______________________________
Address____________________________ City,ST,Zip__________________________
Parents: Please sign below, affirming your child’s request to join the AHOP Onething Project, and giving permission for him/her to attend the Onething conference under the care of AHOP staff.
❑ I Authorize Ron and Mary Burleson to seek medical care for my child, should the need arise. I will not hold AHOP or volunteers liable in any way for any accident that may occur while my child is under their care.
Parent or Guardian Name________________________________
Phone____________________ Cell___________________________ Date_________
Signature_______________________________
Program Cost is $168, due Nov. 15, 2012
❑ We cannot afford the fee, and would like to apply for a scholarship.
Instructions: Please print this application, complete it with your parent's approval and signature, and return to Mary Burleson with payment by November 15.
