WHD Student Intake Form

William H. Douglas Foundation

The Student Advocacy Group
287 South Robertson Blvd. #307
Beverly Hills, CA 90211
Phone: (951) 415-9756
Website: www.whdfoundation.org
Email: foundation@whdfoundation.org

Prospective Student Intake Form
TODAY'S DATE

MonthDayYear
Date
Student First Name
Student Last Name
Street Address
City, State, Zip Code
Cell Phone

Area CodePhone Number
Student Email
example@example.com
Date of Birth

MonthDayYear
Date
Current School Name
Current School Address and Phone
Do you receive Free/Reduced Lunch (Federal Program) at your school?

YesNo
Current Grade Level
Current GPA*
Parent/Guardian Name

Parent/Guardian First NameParent/Guardian Last Name
Parent Street Address
Only complete if Parent/Guardian address is different from Student Address
City, State, Zip Code
Parent, Guardian Email
Colleges that interest you:
What major/subject you plan to study?*
Area of Interest/List up to three
What are your current activities? *
Academic/Volunteer/Social Clubs/Sports
Honors and Awards you received
High School Only
Any additional information you would like to share
How did you hear about us
Each student-based program is customized to maximize WHD Scholar’s opportunities towards their post-secondary and career goals.
William H. Douglas Foundation

Policies and Student/Foundation Guarantee
WHD Foundation and its staff will not be held liable for any harm or injury that may be incurred by students or parents while attending or participating in any Foundation related activity. Student(s) and parent(s) authorize WHD Foundation to edit, alter, exhibit, publish, or distribute students' photo, test results, work or testimonials, waiving his/her right to inspect or approve the finished product or to any form of remuneration. WHD Foundation will be held harmless from any liability by virtue of any distortion or alteration unless it can be proved that such distortions and/or alterations were done with malicious intent. WHD Foundation is authorized to use student or parent information in email lists for the sole use of the Foundation unless the student and his/her parent opt out in writing. All travel expenses that a student incurs shall be the responsibility of the student/parent/sponsor, unless otherwise agreed upon prior to the event. Any additional materials needed or required shall be the responsibility of the sponsor/donor or parent. Student(s) and parent(s) authorize WHD Foundation's staff to visit/communicate with the student's teachers, counselors, and other pertinent personnel. Parent(s) understand that he/she may withdraw this consent in writing at any time. WHD Foundation and its clients agree to indemnify, exculpate, defend, and hold its affiliates and respective shareholders, directors, officer, employees, agents’ successors and assignees harmless from and to reimburse any one or more of the Indemnified Parties for any and all claims, obligations and damages, taxes, and liabilities directly or indirectly arising out of the operation of the Foundation business. This indemnity will continue in full force and effect subsequent to and notwithstanding the expiration or termination of this agreement. All policies contained in this document are subject to change at the WHD Foundation's sole and absolute discretion.

Student Promise: I will do my best and work hard towards my post-secondary goals and aspirations.

Foundation Promise: The WHD Foundation guarantees that it will do everything in its control to ensure student success as long as student adheres to the Foundation's counsel.
Student Signature

Clear
Date

MonthDayYear
Date
Parent/Guardian Signature

Clear
Date

MonthDayYear
Date
WHD Foundation Representative Signature

Clear
Date

MonthDayYear
Date
Sponsor Signature

Clear
Date

MonthDayYear
Date
The information contained in this document is confidential. It is intended solely for the use of the individual(s) or organization(s) to whom it is addressed. Any disclosure, copying or further distribution is not permitted unless such privilege is explicitly granted in writing by The William H. Douglas Foundation. Copyright © 2012-2025 William H. Douglas Foundation
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William H. Douglas Foundation

William H. Douglas Foundation