SFLI | Success For Life Initiative - RDSBC registration form

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SFLi Radical Dreams Success Boot Camp REGISTRATION FORM *(Please Complete and Submit)*
Participant's Name:


Sex:
Male Female

Age:


Date of Birth:


Social Security #:


Home Address:
Street Address Street Address Line 2 City Region Postal / Zip Code Country

Email:


Primary Phone #:
### - ### - ####

School:


School Location: (City, State)


Current Grade in School:


___________________________________________________________
Any other family members attending RDSBC today?
Yes No

If Yes, please list their names:


___________________________________________________________
Mother's Name:


Mother's Address (if different from Participant):
Street Address Street Address Line 2 City Region Postal / Zip Code Country

Mother's Primary Phone #:
### - ### - ####

Mother's Occupation:


Mother's Employer Name, Location (City, State) :


Mother's Work Phone #:
### - ### - ####

___________________________________________________________
Father's Name:


Father's Address (if different from Participant):
Street Address Street Address Line 2 City Region Postal / Zip Code Country

Father's Primary Phone #:
### - ### - ####

Father's Occupation:


Father's Employer Name, Location (City, State) :


Father's Work Phone #:
### - ### - ####

____________________________________________________________ AUTHORIZATION / SIGNATURE:
_{_{I give permission for my child, ________________________________ to}}attend the Radical Dreams Success Bootcamp Weekend during ____________________ 2011._{x Parent / Guardian Signature Date}
_____________________________________________________
In case of Emergency, Please Contact:


Any daily medications required?
No Yes

If Yes, please list medications & doseage:


_____________________________________________________________ STUDENT'S VOICE:
Student Voice Section: Please answer the following two questions in 500 words or less.
_____________________________________________________
#1 Why are you a good candidate for the Radical Dreams Success Bootcamp?


#2 What is your most radical dream?

A survivor is a youth who has successfully “survived” our Radical Dreams Success Bootcamp.

A goal is a dream with a deadline.
– Napoleon Hill

It's easy to make a buck. It's a lot tougher to make a difference.
– Tom Brokaw

There are two great days in a person's life - the day we are born and the day we discover why.
– William Barclay

Of all the attitudes we can acquire, surely the attitude of gratitude is the most important and by far the most life-changing.
– Zig Ziglar

Our attitude toward life determines life's attitude towards us.
– Earl Nightingale

It's not whether you get knocked down; it's whether you get up.
– Vince Lombardi

Great things are not done by impulse, but by a series of small things brought together.
– Vincent Van Gogh

We all have ability. The difference is how we use it.
– Stevie Wonder

Act like you expect to get into the end zone.
– Joe Paterno

Never talk defeat. Use words like hope, belief, faith, victory.
– Norman Vincent Peale

It's not whether you get knocked down; it's whether you get up.
– Vince Lombardi

It's not the will to win, but the will to prepare to win that makes the difference.
– Paul "Bear" Bryant

There are two educations. One should teach us how to make a living and the other how to live.
– John Adams

No one can defeat us unless we first defeat ourselves.
– Dwight Eisenhower

It is not your aptitude, but your attitude, that determines your altitude.
– Zig Ziglar

Great spirits have always encountered violent opposition from mediocre minds.
– Albert Einstein

Great works are performed, not by strength, but by perseverance.
– Samuel Johnson

What lies behind us and what lies ahead of us are tiny matters compared to what lives within us.
– Ralph Waldo Emerson

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