DHGLA 2026-2027 Application

Dear Parents, Guardians & Young Leaders,

The Dr. Harold E. Guinyard Leadership Academy (DHGLA) is accepting applications for the 2026 - 2027 school year. This application is for new and/or returning young leaders.

Please ensure that your application, along with supporting documents, are returned no later than July 31, 2026. It is required that the section on the next page, which refers to a written paragraph, be completed by the student.

Additionally, please become familiar with the attached "Expectations" form for all to follow to remain compliant with the Leadership Academy program.

Thank you for your interest in the growth and development of your son!

Please Note: Completion of this application does not guarantee admission into the DHGLA. Each application is subject to review from the DHGLA Committee. The submission deadline will be strictly enforced. Late entries will not be accepted.

Respectfully,

Phil Roundtree

Committee Chairman

Dr. Harold E. Guinyard Leadership Academy

Pierre E. Rutledge

Chapter President

100 Black Men of South Florida, Inc.

Dr. Harold E. Guinyard Leadership Academy Membership Application 2026-2027

Please provide the parent's information below:
Parent/Guardian Contact #1

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Parent/Guardian Contact #1 Mobile Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Contact #2

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Parent/Guardian Contact #2 Mobile Number
Please enter a valid phone number.Format: (000) 000-0000.
Name of Emergency Contact Person (Someone other than a parent/guardian).
Emergency Contact Person's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian: Please explain why you want your child to become a member of the DHGLA.
Parent/Guardian: How did you learn about the DHGLA and/or who referred you?
Please note that any inaccuracies on this application or at any point throughout the application process, whether intentional or unintentional, may result in the student's removal from the program.
Signature of the parent/guardian

DHGLA Expectations for Young Leaders, Parents and 100 Black Men Mentors

Young Leaders:

1.     Attendance is required at all Saturday sessions and field trips.
2.     Respect your Mentors and each other.
3.     Arrive on time. (Beginning of the sessions and after the breaks)
4.     Be prepared. Always have available pencil or pen and paper.
5. Dress appropriately. (Proper attire will be uniforms per the instructions from the 100; uniform shirt and khakis should be cleaned and pressed)
6.     Actively participate in the session. (Discussions, group activities, leadership roles, volunteer activities)
7.     Be good examples for new Young Leaders and the younger Young Leaders.
8.     Pay attention and follow directions.
9.     Maintain high academic and conduct grades at your school.
10. Exhibit good behavior.
11. Continue to earn your place in the DHGLA.
12. Represent the 100 Black Men positively.
13. Earn the benefits of the DHGLA.
14. Accept whatever consequence meted out to you for inappropriate behavior.
15. Contact your Mentor if you are going to be late and/or unable to attend the Saturday session and/or field trip.

Parents:

1. Communicate with your Young Leaders.

2. Encourage them to be appreciative and excited about the Saturday sessions.

3. Stress the continued respect for their peers and their mentors.

4. Make sure they are dressed appropriately for each session.

5. Encourage your Young Leaders to maintain high academic performance.

6. Make sure they sign in for the Saturday sessions on time. (8:45 am drop-off time; 9:00 am start time)

7. Make sure they have perfect or near perfect attendanee at the Saturday sessions.

8. Make sure they are picked up at the end of the session and/or field trip in a timely manner.

9. lnform the Mentor at the beginning of the session if you are picking him up before the session ends.

10. Support the 100 Black Men positively in your communications with your Young Leaders.

11. Do not hesitate to communicate with the members of the 100 Black Men when you have concerns.

12. Provide approval for the 100 Black Men to access your Young Leader's school records.

13. Respond to the Mentor's corespondence; emails, texts, and/or phone calls.

100 Black Men Mentors:

1. Be good role models.

2. Be prepared for sessions.

3. Be on time to begin the sessions.

4. Treat all Young Leaders equally and fairly.

5. Treat each Youqg Leader with respect.

6. Demand respect from Young Leaders.

7. Respect the confidentiality of each Young Leader.

8. Maintain confidentiality within the leadership Academy Committee regarding in-house issues.

9. Allow open, mentor-facilitated discussions with the Young Leaders.

10. Encourage participation from the Young Leaders.

11. Be the parent when we are with the Young Leaders.

12. Be organized for each session.

13. Demand high academic performance from each Young Leader.

14. Control behavioral issues.

15. Make sure each Young Leader is safe and secure.

16. Communicate concerns with parents.

17. Be a unified front.
Student's Signature
Parent/Guardian's Signature

100 Black Men of South Florida, Inc.

Media Release Form

This Media Release shall confirm the authorization to 100 Black Men of South Florida, Inc. to use my child's media image acquired during Leadership Academy events and activities, including but not limited to photographs, video and/or film productions and print media in furtherance of the organization's goals and activities. (In granting this permission and release, understand that the image may appear in a variety of forums, including but not limited to magazines, newspapers, books, brochures, newsletters, television, videotape, advertisements and the internet.

I release 100 Black Men of South Florida, Inc. from any and all claims arising out of or in connection with the use of such media images, and hereby release, waive and discharge any and all claims, including but not limited to invasion of privacy, defamation, infringement, or other tort. I further warrant and agree that this authorization and release is not in breach of or contrary to any existing rights of another person or entity, and is valid and legally enforceable by 100 Black Men of South Florida, Inc. I further warrant and agree that I have the lawful right to execute this release.
Do you agree to the terms of this Media Release Form?
Student's Name

First NameLast Name
Student's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent's/Guardian's Mobile Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent's/Guardian's Name

First NameLast Name
THE YOUNG LEADER IS REQUIRED TO ATTEND THE DHGLA SATURDAY SESSIONS.

Attendance is required at every Leadership Academy Saturday session. The sessions are from August 2026 to May 2027 twice a month, every 2nd & 4th Saturday from 9:00 a.m. to 1:00 p.m. The Certificate of Completion is awarded to the Young Leader at the end of the program year. The certificate is awarded based on attendance, school grades and participation.

The Young Leader is responsible for contacting the Mentors if he is unable to attend the session; this is an excused absence. If the Young Leader is absent and does not contact the Mentor, this is an unexcused absence. If the Young Leader has four (4) unexcused absences during the first half of the year, he will be placed on probation. Two (2) additional unexcused absences during the probationary period will remove the Young Leader from the program.
Parent's/Guardian's Signature
Should be Empty:

Dr. Harold E. Guinyard Leadership Academy Membership Application 2026-2027

Dr. Harold E. Guinyard Leadership Academy Membership Application 2026-2027