Intensive Excellence Program (SPR2025)

Intensive Excellence Program Application

Please sign up the form below to sign up your middle or high school (8th to 10th grade) student for the Intensive Excellence Program Spring 2025! After completing the form, an email will be sent to you with more information about the program. For any questions please email: dadanladi@gene-xcellence.org
Student Information
Student Name*

First NameLast Name
Birth Date *

YearMonthDay
Phone Number:*
Email
example@example.com
Address:*

Street Address

Street Address Line 2

City

Zip Code
Student's Ethnicity / Race:

African AmericanHispanic/LatinoCausacianOther
Student's T-Shirt Size*
Name of School and Grade*
Last Year GPA (Grade Point Average)*
Parent or Legal Guardian Information
Parent or Legal Guardian (if under 18)*

First NameLast Name
Parent or Legal Guardian Phone Number:*
Parent or Legal Guardian Email *
example@example.com
Parent/Legal Guardian's first language is:*

EnglishSpanishOther
Parent/Legal highest level of education:*

No High School/GEDHigh School Diploma or GEDSome CollegeBachlerMasterPhD
What do you want your child to gain/learn from this program? *
Emergency Contact

For Emergency Contact please list someone other than the person listed for 'Parent or Legal Guardian.' Emergency Contacts will only be contacted when we have not been in contact with student
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Emergency Email*
example@example.com
Emergency Contact's first language is:

EnglishSpanishOther
Household Information
Total number of people living in the household?
What is the total Household Income?
Let's Get to Know the Student Better

These questions are to help us understand the students likes and dislikes as who you are. If you are not sure about any of these questions, type "N/A" in the box.
Does student receive Free or Reduced Lunch?*

YesNo
Is the student currently in Special Education or IEP?*

IEPSpecial EducationNeither
With the last year, has the student participated in any violent or illegal activities?*

YesNo
If "Yes" please give a detailed explanation of what happened.
Do you have any allergies? *
Name any 3-5 things you enjoy?*
What is your dream career? *
Do you want to go to college or trade school? If so, which major and what school?*
What do you want to gain/learn from this program? *
Where did you hear about us? If you were referred put the person's name in 'Other'*

A Friend or colleagueOnline Search (Google, Bing, Yahoo)Social MediaEventOther
Payment Policy

Application fee must be paid before attending the program.
I understand that Gene-Xcellence, Incorporated does not require members to sign a contract for an extended period of time, and members may cancel at any time by notifying a manager. I understand that Gene-Xcellence is a non-profit entity and relies on the prompt club dues payments of members to stay open. I agree to pay my club dues as soon as possible, either by credit card (via the hyperlink on the invoice), Cash, or Check payable to Gene-Xcellence. If I am unable to make a payment, I will notify a club manager and make an arrangement. Club dues are not tax deductible.
Please check if you agree with the Payment Policy:*

I have read and understand the payment policy
Program Expectations

Parents and Students must read and sign the "Intensive Excellence Program Expectation Agreement" that is given separate from this application.
Please check if you agree:*

I have read, understood, and signed the "Intensive Excellence Program Expectation Agreement"
Privacy Policy

Gene Xcellence promises to make all parent and student personal information stays confidential. Please agree to the following:
Check if you understand:

I understand that occasionally, photos and videos from program competitions and practices will be used in promotional material for the program. I agree to allow my image or my child's image to be used for this purpose and that I will not be compensated. I also understand that once a promotional item has been produced, it is not possible to remove my image or my child's image from the production.
Check if you understand:*

I understand that the club will never share my contact information for commercial purposes. I may, however, be contacted by the club managers about club announcements and information relevant to club membership.
Disclaimer and Waiver of Liability
Please know that during any class, event, or any possible field trip Gene Xcellence, Inc. is not resposibles for any injuries, allergic reactions, and any illegal behavior that may take place. Therefore, please have a good time and enjoy yourself but be responsible.
Read above and check the box below:*

I have read, understood, and accept the disclaimer and liability waiver and sign it of my own free will.
Signature of Student*

Clear
Signature of Member's Legal Guardian (if under 18)*

Clear

My Products

Returning Student Fee Only for students that paid the registration fee last year.

$35.00 Quantity

23-24 New Student Fee

$65.00 Quantity

Enter coupon

Total

$0.00

Payment Method
Credit	Express

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Should be Empty:

Intensive Excellence Program Application

Student Information

Parent or Legal Guardian Information

Emergency Contact

Household Information

Let's Get to Know the Student Better

Payment Policy

Program Expectations

Privacy Policy

Disclaimer and Waiver of Liability