DayWorkerIntakeForm

B2L Legacy: RPAC Full Registration Form

Welcome to the final step in joining our B2L Legacy: RPAC Initative. At Build 2 Lead our goal is to provide platforms for those who work in, and or are most negatively impacted by the systems of criminal justice, education, and healthcare to "dream design" solutions and collective power building collaboratives. We appreciate your interest in helping us to build the pathway to systems change!

Ruben Medrano

Program Manager

rmedrano@build2lead.org

"Empower! Engage! Educate!"
Registration Information
First Name*
Middle Name
Last Name*
Gender*
Ethnic background*
Primary Language*
Please specify Other
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Alternate Phone Number*
Format: 000-000-0000.
This is my:*
E-mail*
example@example.com
Best form of contact for all RPAC related meeting request and updates?*

Referral Info
How did you hear about Build 2 Lead?*

ReferralFriend or relativeFlyer or door hangerSocial mediaEmployerOther
Person or agency or organization that referred you
Please specify which social media
Please specify other
Additional Notes
Please use this space to describe your medical restrictions or allergies

Terms and Conditions
Please read carefully:

The undersigned agrees to be bound by all the rules governing Build 2 Lead (B2L) and in addition agrees to the following:

1. Waive any and all claims against B2L, its Board Members, employees, partners and agents for any liability or loss (including but not limited to bodily injury arising out of the programming and activities of B2L).

2. Agree that the stipend of $125 is based upon my attendance at the RPAC meetings. If I do not attend, show up more than 30-min. late, or leave more than 30 min. early I will lose my avility to get a stipend.

3. Will not disclose any data, B2L reports, partner school reports, or any findings from our collective research to any media outlets, out of district schools, or in-district schools (not involved in the RPAC), or any other stakeholders without consent of B2L Leadaershp and the Partner Organizations Leadership.

4. Understand that all RPAC materials, tools, and initiatives are the proprietary designs and intellectual property of Build 2 Lead and Ambition Is Priceless Consulting. RPAC related materials shouldn't be shared with any outside organizations or stakeholders.

By my electronic signature below, I agree to the B2L governing policies and the agreement above.
The Undersigned Client Certifies That:*

All of the above statements are true and completeI have read and agree to follow the rules of B2L initiatives and partner schools.I understand that any violation of these rules will lead to my removal on the RPAC.
Any comments/questions for B2L staff?
Signature (Hold onto mouse and move at the same time to sign)*

Sign by using a touch tablet/screen or left click and hold as you sign with your mouse.
Enter the message as it's shown*

For Staff Use Only
RPAC Sign-Up Overview
Is the applicant still interested after the interest verification phone call?
Date

MonthDayYear
Staff Member:
Has the applicant been cleared to work in schools (If not a staff member)?
Date

MonthDayYear
Staff Member:
Exit Information
Date of Exit

MonthDayYear
Please Select One
Please describe circumstances
Any Comments/Questions about this applicant?
Staff Signature

Sign by using a touch tablet/screen or left click and hold as you sign with your mouse.
Should be Empty:

Registration Information

Referral Info

Current Role/Education Level

Income Level/Resource Supports

B2L Background and Clearance Check Section

Terms and Conditions

For Staff Use Only