Membership Application C.A.S.H. (Creative and Striving Hard) NSBE Jr.

Membership Application C.A.S.H. (Creative and Striving Hard) NSBE Jr.
Student Name*

First NameLast Name
Student Email - Must be different from the parent's email*
example@example.com
Parent/Guardian Name*

First NameLast Name
Parent Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Emergency Contact Person*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Gender*
Current Grade*
School Name*
Primary Racial/Ethnic Identity*
Residency Status*
GPA (cumulative unweighted on a 4.0 scale)*
Anticipated Major*
Favorite Subjects
Did you complete an Algebra class prior to high school?*
Are you interested in being mentored?*
Community Service Activities
Extra-Curricular Activities
Signature of Applicant*

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Signature of Parent/Guardian*

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Date of Signature*

MonthDayYear
Date
Date of Signature*

MonthDayYear
Date
PARENTAL CONSENT

I hereby give my student named below permission to become a member of the National Society of Black Engineers Jr. Chapter (NSBE) Creative and Striving Hard (C.A.S.H.) Program sponsored by LEAP Forward, Inc. and NSBE for the 2024‐2025 year. In giving my permission to participate, I understand that he/she will take part in scheduled meetings, workshops, cultural, educational, and recreational programs including aerobic activities. I agree to provide transportation for my child to all scheduled meetings and activities. If necessary, I agree to allow the below named child to be transported with and by any members of LEAP Forward, Inc. and NSBE. I understand and agree that by signing this consent form, neither I nor my agent(s) will hold LEAP Forward, Inc. or NSBE and those acting on its behalf, liable in the event of harm, injury, or death of the participating child whose name appears below.
Student Name*
Parent/Guardian Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Signature*

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Date of Signature*

MonthDayYear
Date
2024-2025 Photo Release Photography Release Form

Please note your choice regarding being photographed. Please note that granting permission allows us to obtain funding for additional programs that will benefit the student. Check the box below. I hereby grant to LEAP Forward, Inc. and the National Society of Black Engineers (NSBE) Jr. Chapter C.A.S.H. the irrevocable and unrestricted right to use and publish photographs and video of me, or in which I may be included, for publications, electronic reproductions (web sites) and/or promotional materials or any other purpose and in any manner or medium. In addition, I grant my permission to alter the same without restriction; and to copyright the same. I hereby release the photographer and LEAP Forward, Inc. and NSBE Jr. from all claims and liability relating to said photographs. NO STUDENT WILL BE IDENTIFIED BY NAME!!
Consent to Release Form*

YesNo
Student Name*
Parent/Guardian Signature*

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Date of Signature*

MonthDayYear
Date
Liability Release Form (Release of All Claims)

FUTURE TRIPS 2024-2025

For Participation in the LEAP Forward, Inc./National Society of Black Engineers Jr. Pre‐College Initiative Conference/Creative and Striving Hard (C.A.S.H.) trip to the _______________I do hereby release, forever discharge and agree to hold harmless LEAP Forward, Inc., Rhonda Thomas or its Board Members and Volunteers, and agents thereof from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the participant that occur while said person is participating in the above‐described trip or activity including recreation and work activities. The undersigned further hereby agrees to hold harmless and indemnify said Corporation, its Board of Directors, Volunteers, employees and agents for any liability sustained by said acts of said participant, including expenses incurred attendant thereto. The undersigned further consents for the administration of first aid and/or doctor’s care, or any other form of medical treatment necessitated by illness or injury that may require the same. In the event of the necessity of such care or treatments as heretofore described, the undersigned agrees to hold harmless and indemnify said Corporation, its Board of Directors, Volunteers, employees and agents from any acts of malfeasance, and/or failure to act on the part of those chosen to administer medical care on behalf of the participant.

Activity/Trip Coordinator/Chairperson: Rhonda Thomas, President, LEAP Forward, Inc. (301) 337-9660
Student Name*
Student Date of Birth*

MonthDayYear
Date
Student Age*
Participant's Insurance Company and Policy Number*
Home Phone Number*
Please enter a valid phone number.
Cell Phone Number (If Applicable)*
Please enter a valid phone number.
Please include below any additional information or special instructions (e.g. Allergies, etc.) otherwise please note N/A.*
Parent/Guardian Signature*

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Date of Signature*

MonthDayYear
Date
Please provide your shirt size for a chapter polo shirt.*
My Products
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Membership DuesAnnual Membership Dues
$15.00 Quantity

Subtotal

$0.00

Tax

$0.00

Total

$0.00
Payments are accepted via

Cashapp: $leap4ward or Zelle: leapforwardinc@yahoo.com

All others PLEASE complete the paypal credit card payment information below.

Payment Methods

Debit or Credit Card

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