Welcome! Thank you for your interest in our Interfaith Youth Neighborhood Mosaic.

If you have any questions or issues with this form, please contact Taylor R. Muse: [email protected] | (215) 222-1012 x4

Student Contact Details

Name

First

Last

Student Email

Home Phone

Cell Phone

Preferred Contact Method

Email
Phone

Address

Address Line 1

City

State

Zip Code

Which Mosaic program are you applying for?

North Philly (Gesu School): June 9-13, 2025
South Philly (Praise Center): July 14-18, 2025

Date of Birth

Gender

Gender (Self Describe)

What grade will you be in September 2025?

Name of School

Do you have any siblings at home who would also like to participate?

Yes
No

If so, how many and what are their ages?

In 2-5 sentences, please describe what do you hope to learn from this experience?

How did you hear about this program?

Other (please specify

Student Demographic Information (OPTIONAL)

The questions below are entirely optional, and responses do not impact the acceptance of your application. Information is used for grant reporting purposes and to ensure we are best serving the Philadelphia region.

Race/Ethnicity

Other (please specify)

Do you or your family practice a faith tradition/religion? (This is not a requirement to participate in the program)

Yes
No

Faith Tradition

Denomination

Parent/Guardian Contact Information

Salutation

Name

First

Last

Suffix

Relationship to Student

Parent/Guardian Email

Home Phone

Work Phone

Cell Phone

Preferred Contact Method

Phone
Email

Emergency Contact

Name

First

Last

Relationship to Student

Home Phone

Work Phone

Cell Phone

is How (please

Medical Information

Does your child have any food allergies we should know about?

Are there any other accommodations or information we should know about your child?

Release Form

* Release And Waiver Of Liability And Indemnity Agreement

Interfaith Philadelphia requires an electronic signature for our release form. Please download and review the "Release and Waiver of Liability and Indemnity Agreement."

DOWNLOAD WAIVER FORM:

After review, you can submit the Waiver Form by either:

EMAIL: (scan/take a photo and send) to Taylor R. Muse, [email protected]; OR

MAIL: to the Interfaith Philadelphia (Attn: Taylor R. Muse) at 100 W. Oxford St., Suite E-1300, Philadelphia, PA 19122.

By typing your name in the space below, you acknowledge that you consent to the terms of the release form. Thank you.