Save the Polar Bears

First Name:

Last Name:

City:

State:

Zip:

Email:

Phone Number:

Cell Phone:

Your Birthdate:

Will you be a high school junior in the fall of 2011? Yes No

Do you have a passport? Yes No

Name of school:

Name(s) of parent(s) or guardian(s):

Contact phone number for parents:

After you have read the 2010 Leadership Camper blog posts, write your response (maximum 1,000 words) to this question:

"Why would you be the best Arctic Ambassador for Fairfield County?"

(It is recommended that you write your response in a word processor program such as Microsoft Word or Mac Pages, use spell check, and then copy and paste your essay into this box. Do not use any special formatting or fancy fonts.)

Please read and check the box below.

You (the applicant) understand that you are applying to be the representative for Fairfield County at the Polar Bears International Leadership Camp. The selection of the representative will be made based on the quality of the essay and interview. If chosen, you will travel to Churchill, Manitoba, Canada, in October 9-15, 2011. Checking the box below indicates parental approval for application to this program. If you are chosen, you understand that there will be further release of liability and permission forms to be completed and signed.

I have read and agree to the above statement