Clone of 2025-2026 EPIC Enrollment

PICH REGISTRATION

Purposeful Investigations of Careers in Healthcare
PROGRAM REQUIREMENTS

Please email all requested documents in a single email to Programs@100mobile.org. Documents should be attached in PDF Format to
- Overall 2.5 GPA ( Special attention placed on Math and Science course grades)
- Copy of 1st Quarter Report Card ( If selected for interview, bring 2nd Quarter Progress Report)
- Good school attendance record (No unexcused absences/Skipping Classes)
- No Major Behavior Concerns/Disciplinary Infractions (C,D, or E offenses) over previous 2 school years)
- 3 Letters of recommendation
  - 1 - Math teacher from this school year or last to determine Academic Performance/Potential/Growth
  - 1 - Science teacher from this school year or last to determine Academic Performance/Potential/ Growth
  - 1- Admin/Counselor to address Behavior, Character, & Attendance)
- 1 Letter from student expressing reason for interest and qualities that make them a great candidate for selection.
Candidate Information
Child Name*

First NameLast Name
Birth Date*

MonthDayYear
Gender

MaleFemale
Grade*
Name of School*
PARENT/GUARDIAN INFORMATION:
Parent/Guardian Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Secondary Phone Number

Area CodePhone Number
E-mail*
Allergies/Medical Concerns
What skills & resources are you looking for you and/or your child to receive from this program.
Media Permission

I do hereby grant permission to 100 Black Men of Greater Mobile to use the image of my child(ren), such use includes the display, distribution, publication, transmission, or otherwise use of photographs, images, and/or video taken of my child for use in materials that include, but may not be limited to, printed materials such as brochures and newsletters, videos, and digital images such as those on the 100 Black Men of Greater Mobile’s website.
Parent/Guardian Permission

I do hereby freely and voluntarily give my full permission and consent for my child(ren) to participate in Saturday Academy which will be held during the 2020-2021 School Year. I/we grant the 100 Black Men of Greater Mobile, Inc., permission to request quarterly data that will be used to track and assist students to improve academics, attendance, and behavior.
Signature*

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PICH REGISTRATION

PROGRAM REQUIREMENTS

Candidate Information

PARENT/GUARDIAN INFORMATION: