Name (Last)_________________ (First)___________

Name I prefer to be called:_____________________ Age/Grade ____________
Address_____________________________________
City____________________ State______ Zip______ 
Home Telephone______________________________
Parent Work Telephone________________________

Parent/Guardian Name________________________

Parent/Guardian Signature
___________________________________________

Person who told you about the GAP______________

Your Church (if applicable)_____________________

Your Pastor (if applicable)_____________________

PLEASE MAKE CHECK PAYABLE TO:

AND SEND TO:

SPONSOR NAME: Herb Goedecke

SPONSOR STREET NAME & NUMBER
___________________________________________

SPONSOR STATE _______ZIP_____________

Note: Deposit is Non-Refundable

What is the hope in your heart for your future? (your life, your family).

If you could change one thing about yourself, what would it be?

I have attended an information meeting:____ NO____YES DATE _________

I AM COMMITTED TO PARTICIPATING IN THIS TRAINING AS SCHEDULED:

_________________________________________________
SIGNATURE                                                       DATE

If we do not have a minimum of 20 participants by 10 days before the training, the training will be rescheduled.

FOR SPONSOR'S OFFICE USE
CONFIRMATION CALLS:
1) DATE BY
2) DATE BY
REGISTRATION RECEIVED: ________ DATE
FORM OF PAYMENT: _____CASH _____CHECK CK#______
CONFIRMATION LETTER SENT: _____ DATE
FORMS RECEIVED: _______DATE