Join Energeia

Join Energeia and become one of our Long Island youth on the move - making a difference!

 
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Application date:
First name:*
Last name:*
Age:
Grade:
Street address:
Address line 2:
City:
State:
ZIP code:
Home phone number:*
Cell phone number:
Email address:*
School Name:
School district:
Provide three reasons why you would like to be part of Energeia and three things you think you can contribute:
Have you ever been involved in community service? If so, please describe:
Availability: Energeia will be meeting one or two Friday nights a month. Are you available at that time?
Transportation: Energeia will be meeting at the Molloy College Suffolk Center in E. Farmingdale. Will you be able to arrange a ride for all meetings?
How did you hear about Energeia?
Provide a High School reference - person's name:
Reference's position:
Reference's phone pumber:
Reference's email:
Provide a personal or employer reference - Name:
Reference's relationship:
Reference's personal number:
Reference's personal email:
Please share anything else you think may be relevant: