Explore–Lead–Succeed® Pathway Application

Black Scholar Academy™

Explore–Lead–Succeed® Pathway Application
Full Name*

First NameLast Name
Preferred Name

First NameLast Name
Email*
example@example.com
Phone Number*
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Educational Information
College/University*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Major / Intended Major*
Date Expected to Graduate*

MonthDayYear
Date
Current Academic Year*

FreshmanSophomoreJuniorSenior

Pathway Selection
The Explore–Lead–Succeed® pathway allows you to begin where your needs, strengths, and goals align. Please select the phase you would like to start with. Students may complete one phase or the full 12-week journey. Which phase are you applying to begin with?*

1. Explore (Identity & Purpose): For students who want to deepen their self-awareness, clarify their values, and build a strong foundation for leadership and success.2. Lead (Practice & Influence): For students ready to strengthen their leadership skills, grow their confidence, and learn how to positively influence their campus and community.3. Succeed (Career Readiness & Transition): For students preparing for internships, graduation, or next steps, and ready to connect their leadership growth to future goals and impact.
Why did you choose this phase? (100–150 words) Share how this phase supports your goals, current challenges, or areas of growth.*
Identity, Purpose & Leadership

(Short-answer questions: 150–250 words each)
1. Who are you becoming? Share what matters most to you right now and how your identity shapes the leader you want to be.*

0/250
2. Why are you interested in the Explore–Lead–Succeed® pathway? Explain how this program connects to your personal, academic, or leadership goals.*

0/250
3. Describe a moment when you stepped into leadership, formally or informally. What did you learn about yourself?*

0/250
4. What does “Living Legacy™” mean to you? How do you hope to make a positive impact on your campus or community?*

0/250

Optional Supporting Materials

Resume, Leadership portfolio, Letter of recommendation, or a Short video (1–2 minutes) about why you’re applying
File Upload

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Final Reflection
What do you hope to gain from this experience, and what do you hope to give? (100–150 words)*

0/150

Program Commitment Agreement

The Explore–Lead–Succeed® program is a 12-week virtual experience, completed in three phases (4 weeks each): Explore → Lead → Succeed.
Participant Commitments

By signing below, I affirm that:
- I can commit to weekly virtual sessions.
- I can complete weekly activities and reflections.
- I am willing to participate in a community engagement project.
- I understand that scholarships and micro-grants require active engagement.
- I agree to uphold community values of respect, integrity, and contribution.
Certification Statement

I certify that all statements and information I have provided in this application are true and correct to the best of my knowledge. I understand that any deliberate misrepresentation may result in the denial of my application and may prohibit me from applying again in the future.

Black Scholar Academy™ Privacy Statement

Black Scholar Academy™ is committed to protecting your personal information and honoring your privacy. The information you provide in this application will be used solely for the purpose of evaluating your eligibility for the Explore–Lead–Succeed® leadership pathway and for communicating with you about program participation.

We follow privacy practices consistent with the spirit of the Family Educational Rights and Privacy Act (FERPA). This means:
- Your information will not be shared, sold, or disclosed to any third party without your explicit consent.
- Your responses, supporting materials, and personal data will be stored securely and accessed only by authorized BSA™ personnel involved in applicant review, program administration, or scholarship decisions.
- Any data collected may be used in aggregate form only for program improvement, impact reporting, or grant applications, with no identifying details attached.
- Optional materials (résumés, portfolios, videos, or letters) will be treated with the same level of confidentiality as your application responses.
- By submitting this application, you acknowledge that you understand how your information will be used and give permission for Black Scholar Academy™ to review and store your materials for program-related purposes.
If you have any questions about this privacy statement or how your information will be used, please contact us at: admin@blackscholaracademy.org
Applicant's Signature*

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Name of Applicant*

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Date Signed by Applicant*

MonthDayYear
Date
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Black Scholar Academy™

Educational Information

Pathway Selection

Identity, Purpose & Leadership

Optional Supporting Materials

Final Reflection

Program Commitment Agreement