Dreams 2 Life Program Application

4111 West Chapel Hill Street
DURHAM, NC 27701

PROGRAM APPLICATION

APPLICANT INFORMATION

Name

Date of Birth

Age

Grade Level:

Current Address:

Address1

Address 2

City

State

Zip

E-mail:

Phone: Area Code Phone First 3 Phone Last 4

PARENT(S) INFORMATION

Name(s)

Current Address:

Address1

Address 2

City

State

Zip

Phone: Area Code Phone First 3 Phone Last 4

Email:

Fax:

EMERGENCY CONTACT

Name of a relative not residing with you:

Address:

Address1

Address 2

City

State

Zip

Phone Area Code Phone First 3 Phone Last 4

Relationship to Applicant:

PROGRAM(S) OF INTEREST

Arts/Entertainment (Including Culinary Arts)

Community Outreach/ Public Service

Fitness/Athletics/Coaching/Health-Wellness

STEM (Science, Technology, Engineering

Skilled Trades

ADDITIONAL INFORMATION

Hobbies and Interest:

CURRENT SCHOOL

Name

Address

Address1

Address 2

City

State

Zip

Phone Area Code Phone First 3 Phone Last 4

SIGNATURES

Signature of Applicant:

Signature of Parent/Guardian:

ATTACH SLIP HERE

Drag files here or choose files

Submit

DOWNLOAD EXTRA-CURRICULAR ACTIVITY PARENT PERMISSION SLIP

D2L Program Application

PROGRAM APPLICATION

Photo Credit: Morgan Crutchfield

www.morgancrutchfieldphotography.com