Civic Champions Application
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  • GameChangers Summer Leadership Academy

     

    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

    Assistant Program Manager

    dthompson@build2lead.org 

  • Registration Information

  • Format: 000-000-0000.

  • Parent or Guardian/Emergency Contact Info 

  • Referral Info

  • How did you hear about Build 2 Lead?*

  • Housing Status

  • Please check all that apply to your current housing situation and use the space below to describe your situation*
  • If you have secure housing how many adults are in your household?*
  • Are you currently experiencing a crisis?*

  • Health Status

  • Have you or your friends been involved in OR experienced any of the below things? (This information will only be reviewed by Build 2 Lead case management staff and is considered confidential)*

  • Current Grade/Education Level

  • Please check your current grade level*

  • Income Level/Resource Supports

  • Please pick if any supports you will need this school year:*

  • B2L Resource Connection Section

    In this section we will ask questions related to the youth's/young adults involvement in the criminal justice system and struggles with any mental/behavioral health. If you are below the age of 14 please move onto the next section.
  • Have you ever been convicted of a crime ?
  • Are you currently or have you ever been on probation?
  • Are you currently or have you ever been on parole?
  • Would you like a referral for legal services (expungement, taxes, court, legal aid)?

  • Terms and Conditions

  • Please read carefully:

    The participant/parent/guardian and careholder 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 Gamechangers Summer Leadership Academy.

  • The Undersigned Participant and their Parent or Guardian Certifies That:*
  • Reload

  • For Staff Use Only

  •  Programs 

  • Date
     - -
  • Date
     - -

  • Exit Information 

  • Date of Exit
     - -
  • Should be Empty: