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Please print & carefully fill out the following form, then mail with your deposit. |
| Name: |
| Address: |
| City: |
| State: |
| Zip: |
| Telephone - Day: |
| Telephone - Evening: |
| Email: |
| Age: |
| Country of Citizenship: |
| Occupation: |
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Religious affiliation/practice: |
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Why do you want to participate in this project and how do you think you can contribute to its success?
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Have you had any serious health conditions within the past five years? Are you currently taking medication?
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Participants are expected to have good communication skills and a commitment to conflict resolution. What are your strengths in this area?
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How did you learn about this Project?
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| Included with this registration is my $300 trip deposit, paid by ( ) check, ( ) credit card. |
| Please bill my Visa/Master card or Discover card number ___________________________ |
| Print name as it appears on card ________________________ Exp. Date __________ |
