P.O.O.L. Registration Form

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 NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
E-mail
example@example.com
Your Gender
Emergency Contact
Name

First NameLast Name
Relationship To Applicant:
Address

Street Address

Street Address Line 2

CityState / 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?
Additional Information
How did you hear about the P.O.O.L. Program?
Do you have any special needs or require accommodations?
If yes, please provide additional information you would like us to know?
Consent
Full Name of Parent/Guardian

First NameLast Name
Relationship to Applicant:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Income level
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

MonthDayYear
Date
Should be Empty:

P.O.O.L. Registration Form

Emergency Contact

Program Interest

Additional Information

Consent