NEW SCHOLARS APPLICATION 2025-26

You must respond to EACH question/statement. For questions or statements that do not apply and require a text response, please respond N/A; for those that do not apply and require a numerical response, please respond 0.

APPLICANT PHOTO

UPLOAD A PHOTO OF UP TO 1MB

Date Submitted*

Date

Applicant T-shirt size*

Is the applicant eligible for free or reduced lunch during this school year?*

YESNO

Applicant Name*

First, Middle InitialLast, (Suffix Jr, II, III)

Date of Birth*

Date

Age*

Applicant Cell Phone*

Please enter a valid phone number. (N/A if not applicable)

Applicant Email*

example@example.com (N/A if not applicable)

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Custodial Parent/Guardian Name*

First, Middle InitialLast (Suffix Jr, Sr, II, III)

Custodial Parent Cell Phone*

Please enter a valid phone number.

Custodial Parent Home Phone*

Please enter a valid phone number.

Custodial Parent/Guardian Email*

example@example.com

Occupation - Mother*

Mother's Occupation

Mother Work Phone*

Please enter a valid phone number.

Occupation - Father*

Father's Occupation

Father Work Phone

Please enter a valid phone number.

Academics*

School Applicant Will Attend this School Year

City

Grade Level (7, 8,9)GPA

Number of Credits

Applicant Honors & Awards*

Applicant Honors & Awards

Course you Enjoy Most *

Course You Enjoy Most

Course you Enjoy Least*

Course You Enjoy Least

First Career Choice*

First Career Choice

Second Career Choice*

Second Career Choice

Third Career Choice*

Third Career Choice

Courses Enrolled in this School Year*

Courses Enrolled in this School Year

Please List your Hobbies & Interests, Club Participation, Community Engagement, and Leadership Activities*

Hobbies, Interest, Clubs, Community Engagement & Leadership

What college would you like to attend? Why?*

College you would like to attend and why?

Why do you want to participate in the Scholars Academy?*

Why do you want to participate in the Scholars Academy?

RELEASE OF GRADES/BEHAVIOR REPORTS/ATTENDANCE REPORTS

I hereby give my permission for the HRC of 200+ Men, Inc. to have access to my child's grades and progress reports to assist with improvement in academics, attendance, behavior, and study habits while enrolled in this program. I further grant the release of behavior and attendance records. I understand that the HRC of 200+ Men, Inc. will maintain strict confidentiality of this information.

Signature* Date*

RELEASE FOR MEDICAL TREATMENT

In the event of an emergency and the inability of HRC of 200+ Men, Inc. to obtain consent, I hereby give permission for HRC of 200+ Men, Inc. to authorize treatment or surgery in which a qualified physician or surgeon shall deem necessary for my child.

Signature*   Date*

In case of emergency, to which hospital or urgent care do you prefer to have your child transported? Hospital/Urgent Care Facility *      Phone Number*
Primary Care Physician   *   Phone Number*
Medical condition(s) we need to be aware of   *   *   *

PARENTAL ACKNOWLEDGMENT

I hereby give my permission for my child to participate in the HRC of 200+ Men, Inc. Scholars Academy, which may include travel to local, regional, and some instances out of state events. I understand that the HRC of 200+ Men, Inc. is not responsible for personal injury or loss of property. I understand that the success of my child's membership is contingent upon my participation in the program. I agree to immediately update this application when any of the information changes and also on an annual basis.

Signature* Date* Signature Date

PHOTO RELEASE

A. If my son is accepted into the Scholars Academy, I consent and authorize Hampton Roads Committee of 200+ Men Inc., located at 1300 Thomas Street Suite A, Hampton, VA 23669 to use my likeness in any photograph, video, or other digital media (“Photos”) in any and all of its publications, including print or web-based publications.

B. I irrevocably authorize Hampton Roads Committee of 200+ Men Inc. to copy, edit, enhance, crop, or otherwise alter any Photo for use in their publications. I also waive any rights for approval or inspection of any Photos.

C. I understand and agree that all Photos are the property of Hampton Roads Committee of 200+ Men Inc. and will not be returned to me.

D. I acknowledge that I am not entitled to any compensation or royalties with respect to the use of the Photos.

E. I agree to release and forever discharge Hampton Roads Committee of 200+ Men Inc. and its affiliates, successors and assigns, officers, employees, representatives, partners, agents and anyone claiming through them, in their individual and/or corporate capacities from any and all claims, liabilities, obligations, promises, agreements, disputes, demands, damages, causes of action of any nature or kind, known or unknown, which I, and anyone claiming on behalf of me, may have or claim to have against Releasee in connection with this Release

F. I have carefully read and fully understand all the provisions of this Photo Release Form and am freely, knowingly, and voluntarily signing.

Scholar Signature - ONLY if 18 years old

Parent Signature*

NEW SCHOLARS ACADEMY APPLICATION 2025-26