Interfaith Youth Neighborhood Mosaic Application

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

If you need to save this application and return to it at a later time, please click the "Save my progress and resume later" link above, and enter your email address and a password when prompted. When you return to this form later, you will be able to continue your original application by clicking "Resume a previously saved form."

If you have any questions or issues with this form, please contact Elexus Freeman-Filmore: | (215) 222-1012 x4
Student Contact Details

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.

Parent/Guardian Contact Information

Emergency Contact

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."


After review, you can submit the Waiver Form by either:
EMAIL (scan/take a photo and send) to Elexus Freeman-Filmore,; OR
MAIL to the Interfaith Philadelphia (Attn: Elexus Freeman-Filmore) at 100 W. Oxford St., Suite E-1300, Philadelphia, PA 19122.