Date:

Child's Name:
Parent's Name:
Address:
State Zip:
Home Phone:
Contact Person:
Contact person Number:
E-Mail:
Fax #:
Date of Birth:
Current school attending:

Current grade level?
Elementary Middle 
Student T-shirt size:
Special Talents?  yes no
Special Artistic training:
Are there any medical concerns or needs?:

Please mail or fax all information to:
Heart to Heart International Ministries
P.O. box1938 Moncks Corner, SC 29461
Attention:Sis. Fiona Varner PA
Phone 843 345 0519 Fax 843 899 0877

I agree that all the info listed above is accurate to the best of my knowledge.
I understand that I am responsible to inform you of any changes that might
occur in regards to this application.

Sign:
Date: