SCHOLARS ACADEMY APPLICATION

APPLICANT is a:

APPLICANT PHOTO

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Applicant T-shirt size

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)Format: (000) 000-0000.

Applicant Email

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

Income

Number of members in the household

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

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/Guardian Cell Phone

Please enter a valid phone number.Format: (000) 000-0000.

Parent/Guardian Name

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

Parent/Guardian Name

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

Custodial Parent Home Phone

Please enter a valid phone number.Format: (000) 000-0000.

Custodial Parent/Guardian Email

example@example.com

Occupation - Mother

Mother Work Phone

Please enter a valid phone number.Format: (000) 000-0000.

Occupation - Father

Father Work Phone

Please enter a valid phone number.Format: (000) 000-0000.

Name of School Applicant Will Attend this School Year

Name of School Applicant will Attend this School Year

City

City in Which the School is Located

GPA

Grade Point Average from Previous School Year

Applicant Honors & Awards

Course you Enjoy Most

Course you Enjoy Least

First Career Choice

Second Career Choice

Third Career Choice

What college would you like to attend, and why?

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?    Facility Name               Area Code   Phone Number

Primary Care Physician   First Name   Last Name
Area Code   Phone Number

Of what medical condition(s) do we need to be aware?

Medical Conditions

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. 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.

Scholars Signature (ONLY if 18 years old) Date
Parent's Signature Required for Minors * Date*

SCHOLARS ACADEMY APPLICATION

Academics