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Thank you for your interest in the Light America Youth Challenge Program. Simply fill out the application below and we'll get back to you shortly!

Full Name: *

Please give your full name including first and last names.

Email Address: *

We do require your email address

Date of Birth: *

Marital Status:

Single

Married

Gender:

Male

Female

Home Address: *

Please include your street address and your PO Box if any.

City: *

State/Province: *

Zip/Postal Code: *

Home Phone: *

Mobile Phone:

School Information

Name:

Address:

City:

State:

Zip/Postal Code:

Country:

Phone:

Major/Year in School:

If you are in college please put your major and year in school. If you are in high school just put your year in school.

How Long have you been an SDA?:

Have you canvassed before?:

Yes

Why do you want to Canvass this summer?:

What is the earliest date you would be available?:

What are a few things that you like to do in your free time?:

References

First Reference

Full Name:

Phone Number:

Best Time to Call:

Second Reference

Full Name:

Phone Number:

Best Time to Call:

Vehicle Info

Will you be bringing a vehicle with you to the program?:

Yes

Year:

Make:

Model:

Insurance Company:

Insurance Policy Number:

Vehicle Insurance Expires:

Are you taking any medications?:

Yes

If so, please list.:

Do you have any medicine allergies?:

Yes

If so, please list.:

Do you have any food allergies?:

Yes

If so, please list.:

Preferred Area of Work

See Program Locations in the menu.

First Choice:

Second Choice:

Third Choice:

Comments or Questions:

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Light America Youth Challenge

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