Civic Champions Application

Current Grade/Education Level
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5th Grade6th Grade7th Grade8th Grade9th GradeOther
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Terms and Conditions
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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:*

All of the above statements are true and completeI have read and agree to follow the rules of B2L programs and our partner facilities/schoolsI understand that any violation will not be tolerated and will suspend my participation in the GSLA
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Programs
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Date

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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.
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Staff Member:
Exit Information
Date of Exit

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Staff Signature

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Registration Information