Youth Leadership Bridge to College Registration Form

Youth Leadership Bridge to College Registration Form
An 8-week program empowering young leaders through mentorship and hands-on learning with the skills, confidence and resources needed to successfully navigate academic challenges, build strong networks and step into their future with purpose.

Wednesdays March 25th - May 13th: 4:30 PM - 6:30 PM

At LAHC: 5275 Kenilworth St., Dearborn, MI 48126
Name*

First NameLast Name
E-mail*

Confirmation Emailexample@example.com
Phone Number*
Please enter a valid phone number.
School*
Grade Level*

9th Grade10th Grade11th Grade12th Grade
Ethnicity (Please choose all that apply)*

WhiteBlack or African AmericanMiddle Eastern or Arab AmericanAsianAmerican Indian or Alaska NativeHispanicNative Hawaiian or Other Pacific Islander
Address*

Street Address

Address Line 2

CityState

Zip Code
Parent E-mail*

Confirmation Emailexample@example.com
Parent Phone Number*
Please enter a valid phone number.
How do you feel this program will benefit you?*
How did you learn about this program? (Please choose all that apply)*

SchoolFamilyFriendsFormer ParticipantLAHC StaffLAHC FlyerWebsiteOther
Will you be able to attend all of the sessions?*

YesNo
Did you participate in this program before?*

YesNo
If Yes, when?
Important Notice: Participant Consent Form Required

A program participant consent form will be provided to you one week prior to the first session. You may complete it electronically using the link that will be emailed to you, or in person on Day One at the welcome table (a parent/legal guardian signature is required for minors). For questions, please contact Program Manager Jeneen Ali at jali@lahc.org.
This section is to be filled in by Parent/Legal Guardian
Consent*

I agree
This section to be filled by parents or legal guardian ONLY if participant is under the age of 18.!

Registration Agreement: I, the undersigned, hereby authorize my (son, daughter) whose name listed above, to participate in the LAHC- Leaders Advancing and Helping Communities' Youth Leadership-Bridge to College Program. I also give him/her permission to participate in any field trips such as College Campus Tour and/or any outside visits pertaining directly to the fulfillment of the program. In enrolling at LAHC- Leaders Advancing and Helping Communities, participant understands that he/she is attending the program and using LAHC- Leaders Advancing and Helping Communities and the facilities does so at his/her own risk. LAHC- Leaders Advancing and Helping Communities and its owners, employees, board of directors or agents, shall not be liable for any damage whatsoever arising from any personal injury or property loss sustained by participant with his/her family in or about any programs on the premises. Participants and parents assume full responsibility for all injuries and damages which occur in or about any programs on the premises, He/She does hereby fully and forever release discharged hold harmless LAHC- Leaders Advancing and Helping Communities, all associated facilities and its owner, employees, board of directors and agents from any and all claims, demands, damages or rights of action, present or future resulting from any person’s participation in any programs or use of the facility. In addition, he/she agree(s) to follow the rules of conduct and play set by LAHC- Leaders Advancing and Helping Communities. Failure to do so may result in suspension from participation. Consent: I the undersigned parent or guardian/participant do hereby grant authority to the staff at LAHC- Leaders Advancing and Helping Communities to render a judgement concerning medical assistance or hospital care in the event of an accident or illness during my absence. I do hereby authorize LAHC- Leaders Advancing and Helping Communities and its assigns to utilize any and all photographs, pictures or other likeness of me or anyone assigned guardianship to me, as they deem appropriate in its promotional materials or team films.

By entering your name below, you consent to sign the application and give your approval. Please fill in all the fields below.
Name of Parent/Legal Guardian*

First NameLast Name
Relationship to Student*
Phone Number of the Parent/Legal Guardian*
Please enter a valid phone number.
Email of the Parent/Legal Guardian*

Confirmation Emailexample@example.com
Should be Empty:

Youth Leadership Bridge to College Registration Form

This section is to be filled in by Parent/Legal Guardian