THRESHOLDS REGISTRATION FORM |
Return completed form to:
THRESHOLDS
P.O. 114
Thornton, PA 19373
Phone: 610-459-9384
PLEASE PRINT:
NAME ______________________________________________________________________
ADDRESS ___________________________________________________________________
CITY _____________________________ STATE _______________ ZIP ______________
OCCUPATION_______________________________________________________________
EMPLOYER _________________________________________________________________
OTHER SKILLS - EXPERIENCES - INTERESTS___________________________________
_____________________________________________________________________________
TELEPHONE (Home) _________________________ (Work) _________________________
EMAIL ADDRESS_____________________________________________________________
BIRTHDATE ________________________________________________________________
How did you hear about Thresholds? ______________________________________________
Which prison do you think you would like to teach in? (check one or more):
George Hill in Thornton________ SCI-Chester ______Juvenile Center_______
Check all that apply:
[ ] I plan to attend the Volunteer Training Course on January 16 and 17, 2010.
[ ] I cannot attend the January training. Please notify me of the next opportunity.
Check here if you would like to receive our newsletter______
[ ] I have enclosed the fee of $50 ($35 for seniors/retirees and students) payable to
[ ] I am asking for a scholarship.
Signature___________________________________________ Date_______________________