LIFETRAKS APPLICATION

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LifeTraks Student Application

First Name*

Middle Initial*

Last Name*

Street Address*

City*

State*

Zip Number*

Birth Date (MM/DD/YYYY)*

Email Address*

Mobile Number*

Father's Full Name*

Father's Phone Number*

Father's Email Address*

Mother's Full Name*

Mother's Phone Number*

Mother's Email Address*

Authorization*

The student applicant agrees to commit to LifeTraks, agrees to honor and abide by all program rules, and agrees to respect program leadership at all times.The parent gives permission for the student to attend LifeTraks and understands that the student must abide by all program rules, and agrees to respect program leadership at all times. Any inappropriate activities by the student may result in dismissal.

Electronic Signature of Student (Type your name)*

Electronic Signature of Parent (Type your name)*

Click the green "Send Message" button to submit your application.

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Thank you for submitting your LifeTraks application. Your application will be processed, and we will be in contact with you as soon as possible.

Applicants must submit the Student Application and a letter of reference from their pastor in order to complete their application. Letters can be emailed to Pastor Dan Coy at the email address below.

Additionally, parental engagement/communication via email or phone conversation is required before the interview.

CONTACT

LikeTraks Director:

Pastor Dan Coy

Email:

[email protected]

Phone: 540-588-5809