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Note: Please fill out all fields. If you have any trouble filling out this form, please contact us.

About You

First Name & Last Name
Date of Birth
(mm/dd/yyyy)
Age
Do You Have a Social Security Number? No Yes
Citizenship
Citizenship Other (if not U.S.)
Marital Status
Gender
Home Address
City, State & Zip
E-mail Address
Home Phone Number
Cell Phone Number
School
School Address
City, State & Zip
Your Phone Number at School
Year in School
Where do you plan to
attend school next year?
How long have you
been an SDA?
Why do you desire to
canvass this summer?
Your favorite hobbies
What is your favorite kind of music?
Do you speak Spanish?
How did you hear about this program?
If you have an interest in attending Souls-West, please indicate here

References

Name 1 (Pastor)
Address
City, State & Zip
Phone Number
Name 2 (Non-Relative)
Address
City, State & Zip
Phone Number

Parent(s) or Guardian

Father's Name
Mother's Name
Parent/Guardian Address
City, State & Zip
Work Phone Number
Evening Phone Number

STUDENTS AGE 17 AND UNDER: California Youth Rush will send parental permission documents to your parents before the summer.

Please Add Any Additional Comments

Important
Make sure you have filled out all required fields before submitting your application!

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