Thrive360 Leadership Cohort Application
Youth summer program application. Complete all student, parent/guardian, emergency, health, transportation, consent, and signature fields as listed.
Student Information
Student First Name
*
Student Last Name
*
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
School Currently Attending
*
Current Grade Level
*
9th Grade
10th Grade
11th Grade
12th Grade
Recently Graduated Senior
Student Email Address
example@example.com
Student Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Street Address
*
City
*
State
*
Zip Code
*
Parent/Guardian First Name
*
Parent/Guardian Last Name
*
Relationship to Student
*
Parent
Guardian
Grandparent
Other
If Other, Relationship to Student
Best Time to Contact Parent/Guardian
Morning
Afternoon
Evening
Anytime
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Next
Emergency Contacts
Emergency Contact Name
*
Relationship to Student
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Alternate Emergency Contact Name
Relationship to Student
Alternate Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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Next
Health and Medical Information
Does the student have any medical conditions, allergies, or health needs staff should be aware of?
*
Yes
No
If yes, please explain
Does the student take any medication that staff should be aware of during program hours?
*
Yes
No
If yes, please explain
Does the student have any dietary restrictions or food allergies?
*
Yes
No
If yes, please explain
Permission to seek emergency medical care if parent/guardian cannot be reached
*
Yes
No
Parent/Guardian Initials (Emergency Medical Care Permission)
*
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Next
Program Interest and Goals
Why is the student interested in participating in Thrive360?
*
What does the student hope to gain from this program?
*
Leadership skills
Career readiness
Mentoring
Financial literacy
Community engagement
Other
If Other, what does the student hope to gain?
What are the student's current career interests?
What does the student plan to do after high school?
*
Attend college
Attend trade school
Enter the workforce
Join the military
Start a business
Other
If Other, what does the student plan to do after high school?
What type of careers, jobs, or industries would the student like to learn more about?
Transportation
How will the student usually get to and from the program?
*
Parent/guardian drop-off and pick-up
Student drives
Walk
COTA/bus transportation
Rideshare/family member
Other
If Other, how will the student usually get to and from the program?
Does the student need transportation support to attend the program consistently?
*
Yes
No
Unsure
If yes, please explain
Field Trip and Off-Site Consent
Permission for student to participate in program-related field trips and off-site activities connected to Thrive360
*
Yes
No
Consent regarding transportation methods for field trips
*
Yes
No
Parent/Guardian Name
*
Parent/Guardian Signature
*
Date
*
-
Month
-
Day
Year
Date
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Media Release
Permission for student to be photographed, recorded, or included in program media
*
Yes
No
Parent/Guardian Initials (Photo, Video, and Media Release)
*
Program Commitment Agreement
Student Signature
*
Date
*
-
Month
-
Day
Year
Date
Parent/Guardian Consent
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit Application
Submit Application
Should be Empty: