EntreLeadership Application

EntreLeadership Application

EntreLeadership

Welcome to the final step in joining our B2L Direct Program Initative. At Build 2 Lead our goal is to provide quality programs that result in our participants feeling inspired, motivated, and prepared to engage in real world advocacy projects, workforce development career pathways, and build plans for college access and leadership development. We thank you for choosing to sign up for our programs and look forward to helping you "Build 2 Lead!"

Dairyona Thompson

Program Manager

dthompson@build2lead.org
Registration Information
First Name
Middle Name
Last Name
Gender
Ethnic background
Primary Language
Who is completing this form?
What school do you currently attend? Please type full name of school.
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:
Birth Date

MonthDayYear
Email
example@example.com
Student I.D.
Parent or Guardian/Emergency Contact Info
Parent/Guardian Full Contact Name
Parent/Guardian Contact Number
Parent Email
example@example.com
Relationship

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. Indemnity to hold harmless the B2L employees and agents from any and all claims, demands, liability or loss (including, but not limited to, legal expenses or court costs which may arise from or be incurred as a result of any referrals related to our "Entre-Leadership" Program.

By my electronic signature below, I agree to the B2L governing policies and the agreement above.
The Undersigned Client Certifies That:
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For Staff Use Only
Programs
Please choose the primary program that this individual is enrolled in
Date

MonthDayYear
Staff Member:
Based on the "Housing Status," "Health Status," "Income Level/Resource Supports," and "Resource Connection Section" will you be making a case management referral.
Date

MonthDayYear
Staff Member:
Exit Information
Date of Exit

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

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