2025-2026 Flagship Program Appplication

School LEAD Girls of NC Program Application- English
IMPORTANT: Use this form to apply to a School LEAD Program ONLY. If you want to register for the Community LEAD Program, use our Community Application here: APPLY TO THE COMMUNITY LEAD PROGRAM.
APPLICATION & PROGRAM FEES

Thank you for your interest in the LEAD Program! To participate in LEAD, girls must apply, be accepted, and enroll. Girls applying to a school LEAD program will have to pay an application fee. The LEAD program application fee for 2025-2026 is $10.YOU MUST PAY THE APPLICATION FEE TO SUBMIT THIS APPLICATION.

_______

Keeping the LEAD Program running at full capacity helps to make our program accessible to every girl who wants to participate. Making sure that LEAD remains an accessible, life-changing program is always our goal. We appreciate your support!
Participant First & Last Name*

First NameLast Name
Preferred name (if different)
Participant Email address:
example@example.com
Participant Cell Phone
Which program are you registering a participant for? (Name of School Attending 2025-2026)*

Middle Fork Elementary (Middle Fork 5th grade girls only)Cook Literacy Model School Program (5th grade Cook girls only)Paisley IB Magnet School (6th Grade)Paisley IB Magnet School (8th Grade)CrossnoreClemmons Middle School (8th grade girls only)Main Street AcademyWalkertown Middle School (8th grade girls only)Wiley Middle School (7th Grade)
Participant Date of Birth*

MonthDayYear
Participant Age (on September 1, 2025)*
Participant Grade (September 2025) *
Name of School (School attending 2025-2026)*
Participant T-shirt size*

Adult SmallAdult MediumAdult LargeAdult XLAdult XXLAdult XXXL
Name of Parent/Guardian/Primary Contact*

First NameLast Name
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent/Guardian Cell Phone*
Parent/Guardian Place of Employment
Parent/Guardian Work Phone
Email address you/parent/guardian check frequently*
example@example.com
Emergency Contact Full Name*
Relationship to Participant
Home Phone for Emergency Contact Person
Work Phone for Emergency Contact Person
Does your child have any medical conditions, allergies, or special needs the staff should know about? (Please list all known conditions so we can accommodate your child's needs)*
Is your child taking any medications to treat these conditions? If yes, please provide the name of the medication. (**Please note, we do not currently provide medication administration)
Is the participant involved with any other organizations and activities as a member, volunteer, and attend events?*

YesNo
What activities is the participant involved in?
If your LEAD Girl participant is not currently in Crosby Scholars, would you like for her to be enrolled? (The Crosby Scholars Community Partnership helps students in public middle and high schools in Forsyth County prepare academically, personally, and ﬁnancially for college admission and other post-secondary opportunities best suited to each student’s goals, abilities, and needs.) If you select YES, you will receive a separate email with more details.*

YesNoMaybe
Financial Assistance

It is part of our mission to be accessible to girls of all ﬁnancial backgrounds. Applying for a scholarship will neither increase nor decrease your chances of getting into a program. We encourage you to ask for assistance only if you need it, as we only have partial scholarships available.
Are you able to pay $100/year of your child's program fees?*

YesNo
Do you want to apply for Financial Aid to pay for the program fees?*

YesNo

Demographic Information
Directions: Fill out the answers as completely as possible. Please be sure your contact information on the program application is correct. You may be contacted for a follow-up phone interview.
Do you participate in the free lunch program at your school?

YesNo, we don't qualifyNo, my school doesn't have that program
Do you and/or the LEAD Girl participant receive NC Medicaid?

YesNoNot Sure
If you answered YES above, which plan do you and/or your LEAD Girl participant have? Check all that apply.

AmeriHealth Caritas North Carolina, IncHealthy Blue of North CarolinaUnitedHealthcare of North Carolina, IncWellCare of North Carolina, IncCarolina Complete Health, Inc.Other
What is your total gross household income (including child support) for this past year?

Less than $7,000$7,000-$15,060$15,061-$25,820$25,821-$41,960$41,961-$52,719$52,720-$71,010$71,011-$79,080$79,081 or more
How many children live in your home that rely on you (the parents/guardians) ﬁnancially?
Marital status

Never marriedUnmarried, both parents living togetherMarriedDivorced or SeparatedWidowed
Racial background of the LEAD Girl participant (Choose all that apply)

Black/African AmericanWhiteNative American/American Indian/Alaskan NativeAsian/ Paciﬁc IslanderOther
Does the student identify as Hispanic/Latino?

YesNo
What is the highest level of education that you, the parent/guardian, have completed?

Do not have a high school degreeCompleted high school or GEDSome College2-year college/Technical school degree4-year college degreePost-college degree (e.g., Masters, PhD, MD)
LEAD Girls of NC will provide a special "Holiday for HER" experience that allows LEAD Girls and/or their guardians to receive and/or assist with support during certain holidays, such as meal boxes during November, shopping for gifts during December, etc. Please select your desired participation. (You may select more than one. Check all that apply.) **The application is closed for the 2025-2026 Program Year.**
We will have four (4) LEAD program Parent/Guardian sessions. Please select those you would like to attend. Sessions will meet for 60-90 minutes virtually or in-person. (Session topics and dates are TBD. You may select any of the months listed that you are interested in attending. Check all that apply.)

Oct. 2025Jan. 2026Mar. 2026Apr. 2026
Is there anything else you would like us to know?
How did you hear about LEAD Girls?
Required Permissions

We ask permission from every LEAD Girl participant's parent/guardian to include them in photos and/or videos taken during the program, and to ask them about their experience in the program on participant surveys. Your responses below are required for permission.
PERMISSION FOR PHOTOGRAPHY of Participant to LEAD Girls of NC

For valuable consideration received, I hereby grant LEAD Girls of NC (LEAD), its agents and/or assigns the absolute and irrevocable right and unrestricted permission concerning any photographs or other images (hereafter called "media") taken or to be taken of my minor child/participant in LEAD activities in which the participant may be included with others, to use, reuse, publish, and republish the photographs in whole or in part, individually or in connection with other material, in any and all media now or hereafter known, including the internet, and for any purpose whatsoever, speciﬁcally including illustration, promotion, art, editorial, advertising, and trade, without restriction as to alteration; and to use the minor child’s name in connection with any use if LEAD so chooses.

I release and discharge LEAD, its agents and assigns, from any and all claims and demands that may arise out of or in connection with the use of the photographs, including without limitation any and all claims for libel or violation of any right of publicity or privacy.

This authorization and release shall also inure to the beneﬁt of the Board of Directors, legal representatives, and licensees of LEAD. I am a legally competent adult and have the right to contract on behalf of the minor child/participant. I have read this document and fully understand its contents. This release shall be binding upon me and my heirs, legal representatives, and assigns.
Enter your name below for PERMISSION FOR PHOTOGRAPHY of Participant to LEAD Girls of NC*
Type your name in the box.
Informed Consent: LEAD Girls of NC Assessment and Evaluation

To evaluate the effectiveness of our programs, LEAD Girls of NC (LEAD) is conducting research on girls who participate in LEAD programs.

LEAD requests parental/guardian consent for the girls to participate in data collection
at various times throughout the program. Surveys completed by participants are important because they help provide information about the needs of girls when they begin LEAD, and how the girls are doing after they ﬁnish LEAD. In addition to surveys, girls may also be selected for additional research activities, such as participating in a telephone or in-person interview. Parents/Guardians will be notiﬁed if their daughter is selected.

There are no foreseeable risks or inconveniences associated with participation in LEAD surveys or interviews. Girls are free to decline to answer any question they do not wish to answer without providing an explanation. There are no direct beneﬁts from participating aside from improving LEAD and helping girls avoid risky behaviors.

Survey and interview participation is conﬁdential. Responses will not be documented using girls’ names or other identifying information. Girls’ contact information and notes will remain in the possession of the researcher and stored using a password-protected computer.

If parents/guardians or girls have any questions or concerns about surveys and interviews, or desire to offer additional feedback after the surveys and interviews are completed, please contact LEAD Girls of NC at info@leadgirls.org
By entering your name below, this indicates that you are the parent or guardian of a LEAD participant, you have read and understand the information provided above, and freely consent to allow participation in this research.*
Type your name in the box.
Signature: I verify by entering my name below that all the information I have provided in this document is true to the best of my knowledge.*
Type your name in the box.

Application Fee*

LEAD Program Application Fee$10.00

Application fee for applying to participate in the LEAD Program

Enter coupon

Total $0.00

Credit Card

Should be Empty:

School LEAD Girls of NC Program Application- English

APPLICATION & PROGRAM FEES

Financial Assistance

Required Permissions

Credit Card