Interfaith Youth Neighborhood Mosaic Application - 2025

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
Preferred Contact Method
Address
Which Mosaic program are you applying for?
Gender
Do you have any siblings at home who would also like to participate?

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

Parent/Guardian Contact Information

Name
Preferred Contact Method

Emergency Contact

Name

Medical Information

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:

English
Spanish

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.