P.O.O.L. Registration Form
Welcome to the Korey Johnson Foundation P.O.O.L. Program! Please complete the following form to apply for participation in our program. All information will be kept confidential.
Applicant Information:
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
E-mail
example@example.com
Your Gender
*
Please Select
Male
Female
Prefer Not to Say
Emergency Contact
Name
*
First Name
Last Name
Relationship To Applicant:
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Educational Background (Current School Name, Grade Level, Activities):
*
Income Level?
Program Interest
Why are you interested in the P.O.O.L. Program? (Short Essay - 200 words)
*
What are your career goals and aspirations? (Short Essay - 200 words)
*
Do you have any previous leadership experience? If yes, please describe. (Short Essay - 200 words)
*
Are you available to participate in all program activities and events?
*
Yes
No
Additional Information
How did you hear about the P.O.O.L. Program?
*
Do you have any special needs or require accommodations?
*
Yes
No
If yes, please provide additional information you would like us to know?
Consent
Full Name of Parent/Guardian
*
First Name
Last Name
Relationship to Applicant:
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Income level
Please Select
10,000 or less
10,000-20,000
20,000-30,000
30,000-40,000
40,000-50,000
Do you receive free or reduced lunch?
I hereby give permission for my child to be interviewed, videotaped and/or photographed by the media as it pertains to POOL athletic contests. I also hereby release the POOL, Korey Johnson, The Korey Johnson Foundation, and it’s and its agents and employees, from all claims, demands, liabilities whatsoever in the connection with the above. Initials
*
How many people are in the household?
Signature - I hereby certify that the information provided in this application is true and accurate to the best of my knowledge.
*
Date
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: