Application 

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* 1. Student’s Full Name (Ex: Logan Smith)

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* 3. Student's Birthday 

Date / Time

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* 4. What school does the student attend?

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* 5. Student's Home Address

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* 6. Has the student ever participated in a Peace thru Culture program?

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* 7. Guardian #1 Contact Information 

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* 8. Guardian #2 Contact Information

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* 9. Emergency Contact’s Information 

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* 10. Does your child require any ADA accomodations in order for them to participate in the program?

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* 11. Please list any health concerns or food/medicinal allergies that we should be aware of while traveling with your student.

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* 12. Does the student have any dietary needs that we should be aware of?

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* 13. Will the student be required to take any medication while on the trip? 

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* 14. Does your child have an EPI Pen?

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* 15. What is the date of your child's last tetanus shot.

Date / Time

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* 16. Health Insurance Company

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* 17. Does the student receive free or reduced lunch?

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* 18. Student Essay:  Please prepare a short (50 words or less) statement regarding the reason you would like to participate in the Alternative Spring Break DC 2019 program.

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* 19. Which race/ethnicity best describes the student? (Please choose only one.)

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