Nia Association’s Shooting Stars Program Application Form

PERSONAL

Name (Last) _________________ (First) _________________ (Nickname) ______________

Gender ______ Birthdate __________School ______________  Grade _________

Email _________________Home Phone ____________ Cell phone_______________

Parent(s) Name:  ________________________________

Mailing Address:  _________________________________

City ______________________________ Zip ______________

Alternative Number for Emergency Contact: ______________________

ORGANIZATIONS AND ACTIVITIES

Please list the Organizations and/or Activities whereas you are a participant (church, community or school):

Organization/Activity                                                Years of Involvement  

_________________                                                ________________

_________________                                                ________________

_________________                                                ________________

_________________                                                ________________

_________________                                                ________________

GENERAL INFORMATION

What are your career goals?

_____________________________________________

What do you hope to gain from participating in the Shooting Stars Program?

_______________________________________________  
 

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ATTENDANCE

BY signing below you agree to make a commitment to attend each one of the seven classes and the graduation ceremony. 

Signature of Adolescent _________________________________Date ___________

By signing below parent or guardian agrees to ensure that transportation is afforded to the youth for participation.  Nia Association neither guest speakers assume liability for injury or damages arising from participation in the program.  Parent or guardian also consent to Nia Association’s use of any photographs taken or video made of the program.

Signature of Parent/Guardian ____________________________Date ___________

Mail, fax or email application to Nia Association Shooting Stars Program:

Nia Association                        Fax:  (931) 503-0472
c/o Cheryl E. Durham               Email:  cdurham@niaassociation.org
1620 Walnut Grove Road
Clarksville, TN 37042

Note:  It is imperative that applications are received no later than May 30, 2008. You will be notified in writing if your child has been accepted into the program no later than June 9, 2008.