Walking the Walk High School Application 2022

Date of Birth (MM/DD/YY)

Gender

Gender (prefer to self-describe)

Anticipated Year of HS Graduation

Name of School

School District

What is the name of the religious community to which you belong?

Other Religious Community Name

Faith Tradition:

Other Faith Tradition (please specify):

Denomination:

Other Denomination (please specify):

Race/Ethnicity:

Other Race/Ethnicity (please specify):

Questions About You

If you have previously participated in the Walking the Walk youth initiative, please share something about your experience that was most meaningful or memorable.

Describe why you would like to be a Walking the Walk Student Group Leader. Include what you hope to learn and what you hope to offer. What are some of your skills and talents that you will use as a Student Group Leader?

Describe one new activity that would help students get to know one another better.

What will be the biggest challenge for you as a Student Group Leader?

What are your primary extra-curricular activities outside of school? Describe one in detail and why it’s important to you.

Is there anything else relevant to your application that you would like to share other than what you have explored in the earlier questions?

Please write a 3-5 sentence bio about yourself that Interfaith Philadelphia could use on their website. (You may want to include your school, grade, interests/hobbies, why you want to be an SGL, or what you are looking forward to this year in the Walking the Walk youth initiative.)

Parent/Guardian Contact Information (main contact)

Salutation

First Name

Last Name

Suffix

Relationship to Student

Email

Phone Type

HomeWorkCell

Home Phone

Work Phone

Cell Phone

Preferred Contact Method

PhoneEmail

Does parent/guardian live in the same household as student?

YesNo

Enter Parent/Guardian address

Mailing Street

City

State/Province

Postal Code

Enter contact information for secondary Parent/Guardian

Parent/Guardian Contact Information (secondary contact)

Salutation

First Name

Last Name

Suffix

Relationship to Student

Email

Phone Type

HomeWorkCell

Home Phone

Work Phone

Cell Phone

Preferred Contact Method

PhoneEmail

Does parent/guardian live in the same household as student?

YesNo

Enter Parent/Guardian address

Mailing Street

City

State/Province

Postal Code

If parent/guardian cannot be reached:

Emergency Contact Name

Relationship to Student

Emergency Phone Number 1

Emergency Phone Number #2

Medical information

If the student has any condition that might require medication, accommodation and/or special attention, please detail the condition and explain any measures that are needed to provide proper care.

Does your child have any allergies (including food)?

YesNo

If yes, please list allergies:

Medical information such as medications or illness, etc.:

Is there additional information about your child that would be helpful for us to know when working with your child?

YesNoPlease call me.

If yes, please describe:

Physician Name

Physician Phone Number

Please download and review the following documents before completing this form.

Download Interfaith Philadelphia's Youth Program Code of Conduct

* Release And Waiver Of Liability And Indemnity Agreement

Interfaith Philadelphia requires a hand-written signature for our release form. Please print and sign the "Release and Waiver of Liability and Indemnity Agreement." Download Waiver Form.

I intend to submit this form by:

UPLOAD: scan and upload the waiver form hereEMAIL: take a photo and send to Elexus Freeman-Filmore, Youth Programs Manager, at eff@interfaithphiladelphia.orgMAIL: to Interfaith Philadelphia at 100 W Oxford Street, Suite #E-1300 | Philadelphia, PA 19122

Please upload the waiver form

This year's Walking the Walk program is currently planned to be in-person, all masked, and outdoors as much as possible. We will continue to follow CDC and regional guidelines to ensure the safety of all participants and will err on the side of caution.

By typing your name in the space below, you acknowledge that you have read the ‘Code of Conduct’, consent to the terms of the release form, and agree to sign and return the signature page. Thank you.

Walking the Walk High School Application 2022 - 2023

Please download and review the following documents before completing this form.

* Release And Waiver Of Liability And Indemnity Agreement