American Indian Housing Initiative

2002 Alumni Partner Application

Mail to: American Indian Housing Initiative

104 Engineering Unit A

University Park, PA 16802

Fax: 814 – 863 – 4789

1. Contact Information

Name _____________________________________________________________

Address ____________________________________________________________

City ___________________________________ State/Prov __________________ZIP/Postal Code ___________

Daytime phone (____) ______________________E-mail address___________________________________________

2. Penn State Graduation Information

Program ____________________________________________________________ Graduation________

3. Background

Please indicate any construction or related skills that you have that might help contribute to this project or this program.

_____________________________________________________________________________________________________

3. Additional Information

What other information would you like to provide that might help us in the volunteer selection process?

_____________________________________________________________________________________________________

4. Contact in case of an Emergency

Name_________________________________________________________Phone__________________________________

5. Select your preferred trip

Week 1: Date: July 14, 2002 to July 20, 2002 Week 2: Date: July 21, 2002 to July 28, 2002

1^st Choice____________ 2^nd Choice ______________

6. Please reserve ______ space(s) for our participants under age 21 + ______ spaces for our adults = ______ total participants.

Per person registration fees (in U. S. funds): $ 1100 will be requested upon acceptance to the program.

7. Please accept my contribution

Student Sponsor $300 $____________

Program Donation $____________

Check enclosed to Penn State: $____________

FOR OFFICE USE ONLY: Postmark Date ______ Date Received ______ Check______