Beasley Rising Leaders Program Application

Beasley Rising Leaders Program Application
Beasley Rising Leaders is a ten-week strengths-based youth development program rooted in evidence-based curriculum and practices using workshops, team builders, recreational activities, and performing arts. The program will serve 60 Hardeman County youth, ages 5 to 17. Beasley Rising Leaders will meet twice a month on Saturday from 9:00 am to 3:00 pm, with the program launching November 15, 2025.

Applications open 9/15/2025 and applications are due 10/15/2025.

The selected Beasley Rising Leaders participants will be notified prior to 10/31/2025.

Please complete and submit one form per child.
Parent Information
Parent's Name*

First NameLast Name
Parent's Phone Number*

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent's Email*
Student Information
Student's Name*

First NameLast Name
Student's Date of Birth

MonthDayYear
Date
Gender

BoyGirl
What is the youth/child's t-shirt size?
What school does your child attend? *
Grade in (2025-2026)*

KindergartenGrade 1Grade 2Grade 3Grade 4Grade 5Grade 6Grade 7Grade 8Grade 9Grade 10Grade 11Grade 12
Parent Questionnaire
Your child's strengths, interests, and abilities. (Please check all that apply)*

Drawing/ArtBuilding/STEM ActivitiesReading/StorytellingSports/Running/MovementHelping others/caring tasksPerforming (singing, dancing, acting)Leading/teaching othersOther
What is one thing your child is proud of or good at? *
What skills or talents would you or your child like to develop during this program? (Check all that apply)*

Confidence/public speakingSelf-esteem/self-worthProblem solving/math/science/thinkingMaking or keeping friends/teamworkResponsiblity/follow-throughEmpathy/kindness/helping othersLearning how to control their emotionsDevelop coping skillsArtistic Skills (drawing, drama, music)Physical coordination/sportsOther
Please note any medical conditions:
Please note any known allergies:
Does your child require learning/behavioral accommodations? Please describe below.
Would you like the Beasley Rising Leaders program staff to setup a brief behavior/support plan before the program starts?

YESNO
Will your child need transportation assistance?
Beasley Rising Leaders will meet twice a month starting in November 2025-March 2026. Please list any Saturday(s) during this time, your child will be unable to meet.
Authorization to Transport Youth

Authorization to allow another adult (not the parent) to pick up the youth.
Please specify each person, including the name of parents, family members, or relatives, who has permission to pick up your child from the Beasley Rising Leaders Saturday Session.
Authorized Person 1:

First NameLast Name
Phone Number 1:

Area CodePhone Number
Authorized Person 2:

First NameLast Name
Phone Number 2:

Area CodePhone Number
Emergency Contact Information
Please specify each person, including the names of parent, family member, etc. who we should contact in the case of an emergency.
Emergency Contact Person (1)

First NameLast Name
Emergency Contact Phone Number:

Area CodePhone Number
Emergency Contact Person (2):

First NameLast Name
Emergency Contact Phone Number:

Area CodePhone Number
If you would like to serve as a volunteer for the Beasley Rising Leaders, please click the link below to complete the online application.

VOLUNTEER APPLICATION
If you would like to financially support the Beasley Rising Leaders program, please click the sponsorship form below to become a sponsor.

SPONSORSHIP FORM
Program Application Consent
My signature is consent that all information in this application is true and correct*
Should be Empty:

Beasley Rising Leaders Program Application

Parent Information

Student Information

Parent Questionnaire

Authorization to Transport Youth

Emergency Contact Information

Program Application Consent