Burlington Dismas House
 Student Application
 
     
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Prisoner Application
Student Application
Volunteer Application

 

 


Feel free to fill out and submit an application.

 
Name:
Present Address:

Present Phone:

Name and address of parents/guardians:

In case of emergency call:

 

 Birth date:

E-mail address:

 

School:
Major: 
Minor: 

Year 1     2     3     4     grad     other

GPA: 

 

Academic Reference Address:
Personal Reference Address:  
 
Telephone:
 

 


Telephone:
 

 
 
 
Special skill/Talents:
 

Financial Resources/Obligations:
 

Transportation:

Campus Activities:
 

Previous experience with ex-offenders:
 

Personal experience with substance abuse:
 

Why do you want to live at Dismas House?
 

What do you expect to gain from the experience?  What do you feel you can contribute? 

Applying For:
                             (semester, year)

Arrival Date:
                              (expected)