*Print from computer, fill out, and send to:  
3523 E. Beech Wood Lake Rd. 
Bloomfield, IN 47424 (USA)  
                                                     **PLEASE PRINT - USE INK**  
 Full Legal Name (as on your birth certificate and/or 
Name as you would like it to appear on your Prayer Cards and ID 
Street Address__________________________________ 
City_____________________________ State/Province__________  
Zip/Postal Code___________  
(College students, please attach your permanent address and phone number as well.)    
Phone (_____)_______________  
Height__________ Weight________  
Date of Birth: Month _______Day ______Year_______  
Email Address _____________________________________  
Citizenship: (   ) U.S. (   )Canada (   ) Other____________________  
Age______ Sex________ Year of Baptism___________   
 Parent's Name(s)___________________________________________  
Phone (   )____________________  
 Preacher's or Youth Leader's Name __________________________________  
Phone (   )________________  
Church you attend:_______________________________ Member: Y____ N_____ 
Avg. hours per week at church_____  
Street Address_____________________________________ 
City____________________ State/Province___________  Zip/Postal Code___________   
 How did you hear about  Projecti68? ______________________________________________  
1st Choice Team____________________ 2nd Choice Team_____________________ 
 Do you have a current passport? Y_____ N______   passport number?___________________ 
Are you a Projecti68 veteran? Y_____ N_____   
Are you applying for:  
Summer Internship? Y_____ N_____  
A leadership position? Y_____ N_____ (Min. age-22)   
 Why do you want to participate in this project? 
Briefly describe your personal relationship with God 
 (    ) Enclosed is my Application Fee of $35 US ($50.00 Canadian) which is not 
transferable or refundable. Application Fee is not tax deductible. Contributions 
for expenses are tax deductible in the United States when given through Projecti68.  
 ( ) Enclosed is a recent portrait or school photo. Application is not complete 
without your photo.   
 For your free Projecti68 t-shirt (adult sizes) to be given at camp, please check one:  
(   ) Small (   ) Medium (   ) Large (   ) X-Large (   ) XX-Large