Toward a Free and Virtuous Society Student Application

Acton Institute for the Study of Religion & Liberty

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Please indicate which conference you would be able to attend

West Cornwall, CT
August 16-19, 2007

Items in red are required

Student Information	Salutation:
	First Name:
	Middle Initial:
	Last Name:

Mailing Address	Address:
	City:
	State:
	Zip:
	Country:
	Address Valid Until:
	Phone:
	Email:

Alternate Address Information	Address:
	City:
	State:
	Zip:
	Country:
	Phone:
	Address Valid Until:

Personal Information	Marital Status:
	Sex:
	Date of Birth:
	Country of Birth:
	Religious Affiliation:
	Have you participated in other Acton programs? Yes No
	How did you hear about Toward a Free and Virtuous Society conferences?
	For marketing purposes would you please list what magazines, journals, or publications you read on a regular basis:
	If you were referred to us by a professor, please give us the following information about him/her:
	Salutation:
	First Name:
	Last Name:
	School:

Education	What type of degree are you currently pursuing?
	Area of concentration:
	College/University/Seminary:
	Expected Graduation Date:
	Please list degrees you have earned since high school:
	Organizations/Honors/Awards:
	What are your future educational and professional plans?
	Do you hope to be ordained?

Two Academic References

Name:
Address:
Phone Number:
Email:

Name:
Address:
Phone Number:
Email:

Travel Scholarship Information*

Estimated Total Travel Expense:
Amount that you can contribute:
Travel Scholarship requested:

Please describe your need for this scholarship:

*For the benefit of those who need funds for travel, we would ask those who live near a conference site to provide for their own transportation if possible

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Acton Institute for the Study of Religion and Liberty 161 Ottawa NW, Ste. 301 • Grand Rapids, MI 49503 phone: (616) 454-3080 • fax: (616) 454-9454 • email: info@acton.org	Site Map \| Contact Us