View Only Application
Odd Fellows and Rebekahs
UNITED NATIONS PILGRIMAGE FOR YOUTH
Application for Adult Leaders |
Current Photo
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| Full Name: |
_____________________________________________________________ |
| Date of Birth: |
_____________________________________________________________ |
| Address: |
_____________________________________________________________ |
City, State/Province
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_____________________ / ________ Zip/Postal Code: _______________ |
| Phone / Cell Phone: : |
___________________________ / ________________________________ |
| Email: |
____________________________________________________________ |
| Marital Status: |
M-S-D-W Children:Y-N How many?: _____________
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| Present Occupation: |
____________________________________________________________ |
| Order Affiliation: |
Odd Fellow __ Rebekah __ TR __ Jr.OF __ # of Years __________ |
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| Youth Work (Order related):___________________________________________________________________________ |
| Other Youth Leadership Experience:_____________________________________________________________________ |
| Other related activities and interests: _____________________________________________________________________ |
| Skills that may be helpful in the Program (music, drama, etc.): __________________________________________________ |
| Other helpful information: _____________________________________________________________________________ |
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_____________________________________________________________________________ |
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| Applicant signature: ________________________________________________________ Date: _____________________ |
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| Physician’s Statement: |
| The Applicant was examined in my office on (mm/dd/yyyy) ___________
and found to be in good physical condition. |
| Limiting Conditions: _________________________________________________________________________________ |
| Physician's Signature: ________________________________________________________________________________ |
| Address: _________________________________________________________________________________________ |
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| Application approved by: |
| The Jurisdictional UNP Committee |
Jurisdiction: _________________________________ |
| _____________________________________ |
____________________________________________________ |
| _____________________________________ |
____________________________________________________ |
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| Grand Master: ____________________________________________________________________ |
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| Rebekah Assembly President: ________________________________________________________ |
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to download a Tour Leader Application (MS Word) which can be filled in.