A.L.P.H.A Youth Leadership Program

A.L.P.H.A Youth Leadership Program

Thank you for your interest in the Alpha Youth Leadership Program. This program is designed to equip youth with leadership skills, personal development tools, emotional intelligence, life skills, career exposure opportunities, financial literacy, fitness, mentorship, and positive community engagement.
PROGRAM DATES

July 11-

Athletics w/ Derrick Martin (Learning to be Self-Influenced- Self Leadership)

Classroom: Garden to Table with Simply Grace Gardens + Mental Health

July 18-

Athletics w/ Derrick Martin (Learning to Lead amongst peers)

Classroom: Financial Literacy with Wealth Wave + Mental Health

July 25-

Athletics w/Derrick Martin (Leading under Pressure)

Classroom: Mental Health Group Session- Emotional Regulation

August 1-

Field Day- Team Building Activities

Graduation Celebration Ceremony- Family and Parents invited

Program Hours:
9:00 AM – 2:00 PM

Location:

7300 Bruton Rd Dallas, Tx
PARENT/GUARDIAN INFORMATION
Please read carefully before submitting this application. The A.L.P.H.A. Summer Youth Leadership Program is a four-week leadership experience designed to build accountability, life skills, purpose, health, and advancement. Because space is limited, selected participants are expected to fully commit to the program.
PARENT COMMITMENT CONFIRMATION
If No, Which Saturdays can your child attend? Please make sure you child is in attendance on the Saturday's you select.
Acknowledgments
Parent/Guardian Full Name

First NameLast Name
Relationship to Child
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
City
State
Zip Code
Preferred Method of Communication
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Relationship
YOUTH PARTICIPANT INFORMATION
Youth Full Name

First NameLast Name
Date of Birth

MonthDayYear
Current Age
Gender
Additional Children
Youth Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Current Age
Gender
Youth Full Name

First NameLast Name
I understand that attendance at the selected Parent Information Session is mandatory and failure to attend will make this application null and void.
Date of Birth

MonthDayYear
Date
Current Age
Gender
YOUTH BACKGROUND & DEVELOPMENT INFORMATION
Why are you interested in enrolling your child(ren) in the Alpha Youth Empowerment Program?
I understand that if my child is selected, I will be invoiced $25 for the required program T-shirt.
What goals do you hope your child (ren) achieves through this program?
Check all areas where your child may need additional support

Other
Please explain any concerns or challenges your child(ren) is currently experiencing:
Have you noticed any academic concerns?
If yes, please explain.
Have you noticed any behavioral concerns?
If yes, please explain.
Has your child ever been suspended, expelled, or received disciplinary action at school?
If yes, please explain.
HEALTH & SAFETY INFORMATION
Does your child(ren) have any medical conditions?
If yes, please explain.
Does your child(ren) take any medications?
If yes, please list medications and instructions.
Does your child (ren) have any allergies?
If yes, please explain.
Does your child(ren) have any dietary restrictions?
If yes, please explain.
PROGRAM COMMITMENT ACKNOWLEDGMENT
Parent/Guardian Signature
Should be Empty:

A.L.P.H.A Youth Leadership Program

Additional Children