Welcome and thank you for your interest. This program is for youth and young adults ages 12-24, who identify as Black or African Descent living in King County, WA. Your application will be reviewed and confidentially processed. You will be notified by email if you are accepted in the program. Please make sure your contact information is correct.
Participant First Name
Participant Middle Name
Participant Last Name
Have you attended an information session?
Participant phone number
Street address 1
Street address 2
School status for fall 2019
Enrolled in GED program
High school diploma (completed)
Currently suspended or expelled
Not completing high school
Employed - full-time
Employed - part-time
Employed - seasonal
Not employed - looking for work
Not employed - unable to work
Not employed - not looking for work
Date of birth
How do you identify
Prefer not to say
Parent/ Guardian/ Caregiver Information
Please complete this section if you are under 18 years of age
Parent/ Guardian/ Caregiver full name
Parent/ Guardian/ Caregiver phone number
Parent/ Guardian/ Caregiver email
Media release- I understand that participant's image maybe captured on video/photography. I give permission and understand that there is no compensation provided for any appearance or statements recorded *
I do not consent
Liability Waiver- I understand that there is a risk involved in physical activities and do not hold the institute or affiliates liable for any injuries or chronic condition that might develop as a result of participating. *
I do not consent
Please tell us why you are interested in the Embrace Your Best Self Program and/or tell us what you hope to experience.
Please tell us your ideas about what it means to be a successful adult.
I certify to the best of my knowledge all my responses are accurate and truthful.
Please verify that you are human
How did you hear about this?
Name of person or organization
Should be Empty: