Application for Program - La Maison de Perrine

Application Form

First Name

Middle Name

Last Name

Nickname (if you have one)

Date of Birth

Gender

Male

Female

Primary Email

Secondary Email

Home Phone

Mobile Phone

Country(ies) of Citizenship

Current Mailing Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Please list carefully any illnesses, allergies or conditions (physical or mental). Pre-existing medical conditions not listed in your application, which become evident later, may result in the rejection of your application with no refund, or your early termination and dismissal at your expense.

Please use this field to elaborate on anything in this part of the application

Which program are you applying to?

Person to notify in case of emergency

First Name

Middle Name

Last Name

Relationship to Student

Mobile Phone

Home Phone

Work Phone

Contact #2

First Name

Middle Name

Last Name

Relationship to Student

Mobile Phone

Home Phone

Work Phone

Student Disclosure and Approval of Participation to be completed by applicant:

Please review the following statements very carefully, select each checkbox to indicate your agreement, and sign at the bottom of this section.

I understand that I am applying for a Christian faith-building program and am expected to participate fully in all program lectures and activities while attending the program week at La Maison de Perrine Christian Centre.

I certify that the information disclosed in this application is true to the best of my knowledge.

I consent to have Elite Education store my submitted information so they can respond to my application.

I understand that if I choose to leave the program early, that no refund is payable.

Date

Electronic Signature (Full Name of Student)

Please write a few sentences about what motivates you to attend our program. Please include comments about your religious background.

Application Checklist

Prior to sending in your application, please double-check that you have completed the following components:

Application
$200 non-refundable application fee*
*This will be refunded in the event that your application is not accepted

Venmo: Jerry-Jones-393
Zelle: [email protected]
Wells Fargo: routing # 121042882 a/c # 3313513495

PLEASE MAKE SURE THAT IT’S CLEAR WHO THE MONEY IS FROM

If your application is successful, there will be a couple more forms to submit before final acceptance.