BluePrint for Success 2025

Dear Applicant,

We are pleased to introduce the Blueprint for Success program, tailored for youth 14-18. Our mission is to support your educational and career goals by offering personalized mentorship, skill-building workshops, and connections to valuable resources.

By participating, you'll gain guidance in career exploration, educational advancement, and personal development, all aimed at enhancing your socio-economic prospects.

Sessions will be held on Mondays at 1624 S. Pulaski, Chicago, IL. 60623 from 6:00 PM-8:PM. Also 2nd and 4th Saturdays from 4PM-6PM.

We look forward to supporting you on this transformative journey.

Sincerely,

The Blueprint for Success Team
What is your ethnicity?
- Youth Full Name
  
  First NameMiddle NameLast Name
- Gender
- Birth Date
  
  DayMonthYear
- Mobile Number
  
  Area CodePhone Number
- E-mail
  example@example.com
- Current Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry
- Are you participating in any other mentoring program? If yes, which one?
- How many years have you participated in Project Impact 180 programs?
- Tshirt Size
  
  Other
- Current School name
- School contact person
- Current Grade
- In no more than 250 words , why do you want to participate in the BluePrint for Success Program?
  
  0/250
- Major or Area of Study
- Interested Major
- Other Course
- Current grade point average (GPA)
- GPA Scale
- Class Rank (if applicable)
- English Proficiency
- Test Score
- Have you ever taken the SAT test before?
- If yes, what is your total test Score
- Activity 1
- Activity 2
- Activity 3
- Achievements
- Hobbies / Interests
- Other Hobbies/ Interests
- Community Engagement: "In what ways have you been involved in your community, and how do you plan to continue or expand this involvement through the Blueprint for Success program?"
  
  0/250
- Parent/Guardian Name
  
  First NameLast Name
- Parent/Guardian E-mail
  example@example.com
- Guardian Phone Number
  
  Area CodePhone Number
- Relation to the youth
- To ensure the safety and well-being of all participants, it's essential to gather comprehensive medical information. Please provide details regarding any medical conditions, allergies, medications, or other health-related concerns that may affect your child's participation in the program. This information will enable us to offer appropriate care and accommodations as needed.
- Please list any chronic or acute medical conditions (e.g., asthma, diabetes, epilepsy) that your child has:
- Allergies: Specify any known allergies, including reactions to food, medications, or environmental factors that your child has:
- Medications: List any medications your child is currently taking, including dosage and administration times
- In the event of an emergency, I authorize Project Impact 180 to secure medical treatment for my child. I understand that reasonable efforts will be made to contact me prior to administering medical care. I agree to be responsible for any medical expenses incurred
- Do you or your parents receive any of the following? select all that apply :
- How many people live in your house including you?
- To ensure a comprehensive evaluation for the Blueprint for Success program, we kindly request applicants to submit the following documents. Please ensure all files are of high quality and in either .PDF or .JPEG format, with each file not exceeding 500 KB in size.
  
  Required Documents:
  - Current Grades/School Transcript
  - Recommendation Letter: A letter from a high school teacher or counselor endorsing your application.
- Elementary/High School/College Transcript (doesnt have to be an official copy)
  
  Upload a File
  
  Cancelof
- Recommendation Letter (please submit before the first day of session)
  
  Upload a File
  
  Cancelof
- Is there any other information that you would like to share with us?
- Did you have any problem while filling out this form? If so, please report it below
- Program Participation Consent: I, the undersigned, certify that I am the parent or legal guardian of the above-named participant. I grant permission for my child to participate in the Blueprint for Success Program, including all associated activities and events.
- Liability Waiver and Release: I understand that participation in the Blueprint for Success Program may involve inherent risks, including, but not limited to, physical activities and transportation. I hereby release, discharge, and hold harmless Project Impact 180, its officers, employees, agents, and volunteers from any and all claims, liabilities, or damages arising out of or in connection with my child's participation in the program
- Medical AuthorizationIn the event of an emergency, I authorize [Organization Name] to secure medical treatment for my child. I understand that reasonable efforts will be made to contact me prior to administering medical care. I agree to be responsible for any medical expenses inc
- Photo and Media ReleaseI grant permission for Project Impact 180 to photograph, videotape, or otherwise record my child's image and/or voice during program activities. I consent to the use of such recordings for promotional, educational, or informational purposes in print, digital, or broadcast media. I understand that my child's name may be used in connection with these recordings unless I specify otherwise in writing.
- Confidentiality and Data ProtectionI acknowledge that Project Impact 180 will collect and maintain personal information about my child for the purpose of administering the program. I understand that this information will be kept confidential and will not be shared with unauthorized parties. I consent to the collection and use of this information as described, in compliance with applicable privacy laws.
- By signing below, I, as the parent/legal guardian of the participant, confirm that I have read and agree to all the terms and conditions stated above
- Signature
- Should be Empty: