Application Form

Please print out this form and complete all the requested information to the best of your ability. Applications must be returned to: THE PIKE COUNTY FEDERATION OF SPORTSMEN'S CLUBS, P.O. BOX 681, MILFORD, PA 18337. Do not e-mail the application. E-mail submissions will be refused. A check for the student fee of $50.00 must accompany the application. All checks must be made payable to THE PIKE COUNTY FEDERATION OF SPORTSMEN'S CLUBS. The application, check, and any accompanying support material (eg. letters of recommendation) should be received by the Federation no later than June 30th.  Late applications may be accepted if space is still available.

 

Name:

  

Date of Birth:
 

Address:

  

Boy or Girl:

  

 T-Shirt Size
 

City State Zip:

 Home Telephone:

Work Telephone:
 

Parent(s) Names(s):

  

e-mail:
 

School District:

  

School Grade Completed:
 

Favorite Subjects:
 

Extracurricular Activities, Honors, or Awards:
 

Hobbies:

Please list any outdoor interests you have or special conservation programs that you may have participated in:

 

 
The main purpose of the Conservation School is EDUCATION. In a short essay of no less than 100 words, please state your reasons for wanting to attend the school AND how you will put the knowledge obtained to good use. Please an additional 8 1/2 x 11 sheet of paper and attach it to the application. Be sure to write legibly.

List at least two people that can be contacted for a recommendation. (It would be extremely helpful to the selection committee if at least one letter of recommendation accompanies the application. However, please do not hold the application past the deadline to await the letter of recommendation.)
 

Reference Name:                                                  Reference Name:
 

Address:                                                                 Address:
 

City State Zip:                                                        City State Zip:
 

Telephone:                                                             Telephone:
   

 

The following must be completed by the applicant's parent or guardian:

 

_______________________________ has my permission to take part in the Pike County Federation of Sportsmen's Clubs' Youth Conservation School at Lacawac Sanctuary and to travel to other facilities and locations for educational programs. The signing of this application releases the Pike County Federation of Sportsmen's Clubs Inc. and the Lacawac Sanctuary Foundation Inc. and any participating organizations, agencies, and volunteers from all claims for accidents or injuries incurred by the applicant in the normal course of instruction. A medical permission form will be sent to each selected applicant for completion.

                        _______________________________          _________________

                            signature of parent or guardian                               date