Name:
Address:
City:		State:	Zip:
Phone:		Cell:
Age:		Grade:
E-Mail:

Are you willing to be sequestered at a local retreat for the night?	Yes  No
Are you willing to write a "good-bye" letter to your family/friends as part of the program?	Yes  No
Would you be willing to read your letter to the audience at the assembly?	Yes  No
Are you willing to participate in a simulated traffic collision?	Yes  No
Would you be willing to be placed in a body bag?	Yes  No
Would you be willing to be the critically injured patient, who dies after being transported to the hospital?	Yes  No
Would you be willing to play the part of the drunk driver, perform field sobriety tests and go to jail?	Yes  No

List school and/or outside activities:

What do you like to do on the weekends:

What is the purpose for the EVERY 15 MINUTES program?

Why are you interested in being part of the program?

Why should you be chosen to participate in Every 15 Minutes?

For the Every 15 Minutes Program to be effective, it is necessary that you do not discuss this application or the program with other students or faculty.