Cap Corps Preliminary Information Form

I. Basic Information

                                            
Name:
Birth Date:
                                            

Ia. Temporary Contact Information

                                            
Address 1:
Address 2:
City:
State:
Zip:
Phone:
                                            

Ib. Permanent Contact Information

                                            
Address 1:
Address 2:
City:
State:
Zip:
Phone:
Email:
                                            

II. General Information:

                                            
Sex:
Male:
Female:
                                            
Marital Status:
Single:
Married:
Divorced:
Single w/ Dependents:
Married w/ Dependents:
Divorced w/ Dependents:
                                            
No. of Dependents:
Citizenship:
Religious Affiliation (optional):
                                            
What type of service interests you?
                                            
Are you able to make a long term commitment?
Yes:
No:
                                            
Are you able to begin in early August?
Yes:
No:
                                            
Describe any physical/medical health concerns:
                                            

III. Educational Background
                                            
Education Background:
College/University:
Major:
Degree:
Graduation Date:
                                            
High school graduate:
Yes:
No:
                                            
Graduation Date:
                                            
Current Work or Volunteer Service:
(Please provide type of work, agency/employer, city, state and dates employed)