• Civitan Leaders In Freedom Conference (LIF) - Student Application

    Civitan Leaders In Freedom Conference (LIF) - Student Application

    Piankatank Camp & Conference Center, Hartfield, VA December 6-8, 2019
  • All application submissions will receive a confirmation letter within 10 days of submitting your information from the Leaders In Freedom Coordinators. Your confirmation letter will require both parent and student signatures and will need to be emailed back to ChesapeakeJrCivitan@gmail.com before any student is considered confirmed.
  • If you do not receive a confirmation letter, please contact ChesapeakeJrCivitan@gmail.com.
  • Student Info

    All fields are required

  •  -
  •  - -
  • Parent/Guardian Info & Emergency Contact

    Once application is received, a confirmation letter will be emailed to student and parent for signatures.

  •  -
  •  -
  • School Info

  • Medical Information

    Completed student medical Information and release form is a requirement of attending the conference. This information will be included on the confirmation form for signature. No student will be accepted without this information.
  •  -
  •  - -
  •  - -
  • Coordination Info

  • Understanding:

    By clicking 'accept' below, I confirm that I understand that I am not a confirmed participant until I have sent back the parent and student signed confirmation letters and received an email stating that I have been confirmed and extended a fully-paid sponsorship. If I have any questions, I will contact ChesapeakeJrCivitan@gmail.com
  • Should be Empty: