Project Shine Participant Registration 2022
June 19-24, 2022
Hosted at Goss Memorial Church: 2247 11th St SW, Akron, OH 44314
Contact us for more information at (330) 573-9591 or projectshineakron@gmail.com
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Participant's First Name *
Last Name *
Preferred Email Address *
I am participating as a.... *
Street Address *
City *
State *
Zip Code *
Preferred Phone Number *
Gender *
Date of Birth *
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DD
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Have you participated in the past? *
T Shirt Size (Adult Sizes) *
Affiliated Church/Organization Name *
Youth/Church Leader or Pastor's Name *
Experience/Skills
ADULTS PARTICIPANTS ONLY - Availability
Morning
Afternoon
Evening
Flexible
FULL DAY
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
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Committed a Crime? *
If Yes, explain...
Health Insurance Provider *
Policy/ID Number *
Insurance Phone Number *
Date of Last Tetanus *
MM
/
DD
/
YYYY
Allergies & Reactions...
Medical Conditions...
Medications
(1) Emergency Contact Name *
(1) Emergency Contact Phone Number *
(1) Relationship of Emergency Contact *
(2) Emergency Contact Name *
(2) Emergency Contact Phone Number *
(2) Relationship of Emergency Contact *
I have reviewed the expectations for involvement in the 2022 Project Shine work week. *
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I have reviewed the General & Financial Info for involvement in the 2022 Project Shine work week. *
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