Diabetes Camp of West Virginia
Leadership in Training (LIT) Application


 Send Completed Applications to: Camp Kno-Koma, PO Box 224, Dallas, WV 26036-0224
Applications must be postmarked by April 15, 2008 


General Information

Last Name                                                              First                                               M.I.

  

Date of Birth

  

Sex

Home Phone

E-Mail Address

Street Address

  

City

County

State

Zip

T-Shirt Size

         

 

Insulin Type (e.g. Humulin, Novolin,etc.)

  

Emergency Contact Name and Phone Number

Have you attended Camps in the past? If so, describe type (i.e. church camp, 4H, diabetes,etc) and how many years 

 

.

List any special talents (singing, acting, etc.), skills (swimming, canoeing, etc.), certifications (CPR, Lifeguard, etc.) or hobbies

   

 

 

 

Please attach to this application a letter describing the following:

Please include reference letters (2 minimum) from the following suggestions:

·        Educational reference (teacher, principal, guidance counselor)

·        Community reference(volunteer work, church)

·        Personnel reference (friend, coach, advisor, neighbor)

·        Employer reference (babysitting included)