Education and Community Leadership Programs Form

EDUCATION & COMMUNITY LEADERSHIP

Program Application 2025 - 2026

Promoting personal development is paramount to the holistic success of the youth and families, as supported by the Pinellas County Urban League Education Department.

To facilitate their journey toward success, our education programs offer avenues for enhancing educational achievement, honing leadership abilities, and fostering social and character development.

Tamika Mitchem| Community@pcul.org | 727.327.2081

WHICH PROGRAM ARE YOU APPLYING FOR?*

Project Ready (Formerly N.U.L.I.T.E.S) (GRADES 6 - 12) - nurtures the development of youth and their post secondary pursuits including college and career navigation, character-building, and community responsibility, all required to create and mold the next generation of civic leaders and professionals.Urban Youth Empowerment Program (U.Y.E.P.) - Transform your future with the Urban Youth Empowerment Program (UYEP), a career readiness initiative designed to empower underserved youth to overcome challenges and unlock their full potential—open to ages 14 to 19 in Pinellas County!Y.C.P.I.P. (Youth Crime Prevention & Intervention Program) Join us in building a stronger, more secure community with our mission to empower children and families through transformative justice initiatives funded by Florida’s Office of the Attorney General. Our innovative programs, grounded in restorative justice, foster impactful dialogues and inspire youth to embrace social accountability, reflecting on and improving their everyday interactions.JUNIOR N.U.L.I.T.E.S. (GRADES 3 - 5) - Junior nurtures the development of youth and their post secondary pursuits including college and career navigation, character-building, and community responsibility, all required to create and mold the next generation of civic leaders and professionals.

Name*

First NameLast Name

E-mail*

Phone Number*

Area CodePhone Number

ADDRESS*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Birth Date*

MonthDayYear

AGE*

GENDER*

MALEFEMALE

ETHNICITY*

NAME OF SCHOOL *

GRADE*

GPA*

SHIRT SIZE*

PARENT/GUARDIAN*

First NameLast Name

ADDRESS (IF DIFFERENT FROM STUDENT)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

E-mail*

example@example.com

Phone Number*

Area CodePhone Number

PARENT/GUARDIAN

First NameLast Name

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

E-mail

example@example.com

Phone Number

Area CodePhone Number

EMERGENCY CONTACT NAME*

RELATIONSHIP TO PARTICIPANT*

CONTACT NUMBER*

HOW DID YOU HEAR ABOUT OUR PROGRAMS*

WHY DO YOU WANT TO PARTICIPATE IN A PCUL YOUTH PROGRAM?*

WHAT DO YOU HOPE TO GAIN WHILE PARTICIPATING IN THE PROGRAM?*

WHAT ARE YOUR PLANS/GOALS FOLLOWING HIGH SCHOOL/COLLEGE?*

DO YOU HAVE ANY CURRENT EDUCATIONAL BARRIERS OR NEEDS?*

I *, DO HEREBY AUTHORIZE PINELLAS COUNTY SCHOOLS TO RELEASE REPORT CARD/PROGRESS REPORT INFORMATION TO INCLUDE CURRENT CONTACT INFORMATION, REGARDING MY CHILD’S PARTICIPATION IN THE PINELLAS COUNTY URBAN LEAGUE’S PROGRAMS OR ACTIVITIES. THIS INFORMATION SHALL BE RELEASED TO THE PINELLAS COUNTY URBAN LEAGUE’S REPRESENTATIVES FOR THE PROGRAM SELECTED ON PAGE ONE OF THIS INTAKE FORM.

I UNDERSTAND THAT THERE ARE NO CONSEQUENCES FOR MY FAILURE TO AUTHORIZE THE RELEASE OF THE PARTICIPATION INFORMATION DESCRIBED ABOVE.

PARENT/GUARDIAN INITIAL HERE*

WE HEREBY GIVE PERMISSION TO THE PINELLAS COUNTY URBAN LEAGUE, ITS EMPLOYEES AND AGENTS, TO TAKE AND USE PHOTOGRAPHIC, VIDEO, DIGITAL OR AUDIO IMAGES OF PARTICIPANT. VISUAL/AUDIO IMAGES ARE ANY TYPE OF RECORDING, INCLUDING BUT NOT LIMITED TO PHOTOGRAPHS, DIGITAL IMAGES, DRAWINGS, RENDERINGS, VOICES, SOUNDS, VIDEO RECORDINGS, AUDIO CLIPS, OR ACCOMPANYING WRITTEN DESCRIPTIONS. PCUL WILL NOT MATERIALLY ALTER THE ORIGINAL IMAGES. I UNDERSTAND THAT PCUL THE IMAGES AND ALL RIGHTS RELATED TO THEM. THE IMAGES MAY BE USED IN ANY MANNER OR MEDIA WITHOUT NOTIFYING ME, SUCH AS EDUCATION, INFORMATION, PROMOTION, PUBLIC RELATIONS, WEBSITES, BROADCASTS, ADVERTISEMENTS, POSTERS AND FUND RAISING. I WAIVE ANY RIGHT TO INSPECT OR APPROVE THE FINISHED IMAGES OR ANY PRINTED OR ELECTRONIC MATTER THAT MAY BE USED WITH THEM. I UNDERSTAND THAT I WILL RECEIVE NO PAYMENT FOR THE USE OF THE IMAGES IN WHICH I APPEAR. I RELEASE THE PCUL AND ITS EMPLOYEES AND AGENTS, INCLUDING ANY FIRM AUTHORIZED TO PUBLISH AND OR DISTRIBUTE A FINISHED PRODUCT CONTAINING THE IMAGES, FORM AND ANY CLAIMS, DAMAGES OR LIABILITY WHICH I MAY EVER HAVE IN CONNECTION WITH THE TAKING OF AND USE OF THE IMAGES OR PRINTED MATERIAL USED WITH THE IMAGES.

PARTICIPANT OR PARENT/GUARDIAN INITIAL HERE*

PLEASE LIST ANY ALLERGIES:*

CHECK THE OPTION THAT BEST MEETS THE MEDICAL RESPONSE FOR YOU AND/OR THE PARTICIPANT:

IF DURING THE NULITES PROGRAM THE PARTICIPANT (MYSELF OR MY CHILD), IN THE OPINION OF THE YOUTH ADVISORS/OFFICIALS IS IN NEED OF EMERGENCY MEDICAL/HOSPITAL CONSULTATION OR TREATMENT, I HEREBY:*

I AUTHORIZE CONSULTATIONS OR MEDICAL TREATMENT AS DEEMED NECESSARY WITHOUT NOTIFICATION TO MY EMERGENCY CONTACT PERSON IF SAID INJURY IS DEEMED LIFE THREATENING OR LOSS OF LIMB AND/OR EXTREMITY IS INVOLVED.IN THE CASE OF ALL MEDICAL EMERGENCIES, MY EMERGENCY CONTACT SHOULD BE NOTIFIED BEFORE TREATMENT IS ADMINISTERED.DUE TO RELIGIOUS OR PERSONAL BELIEFS, I DO NOT AUTHORIZE CONSULTATIONS OR MEDICAL TREATMENT.

I UNDERSTAND AS THE PARENT/GUARDIAN OF THE PARTICIPANT, THAT THE PARTICIPANT IS FULLY RESPONSIBLE FOR THE APPROPRIATE, TIMELY, CONSISTENT AND COMPLETE ADMINISTRATION OF ALL HIS/HER EXISTING, PROFESSIONALLY PRESCRIBED MEDICAL CARE, INCLUDING ROUTINE MEDICATIONS, ANTIBIOTICS, AND ORTHOTIC DEVICES AND WOUND CARE.

PARTICIPANT OR PARENT/GUARDIAN INITIAL HERE*

PARTICIPANT SIGNATURE*

TODAY'S DATE*

Date

PARENT/GUARDIAN SIGNATURE*

TODAY'S DATE*

Date

Thank you for your interest in a Pinellas County Urban League youth program. Once you've submitted your application, a member of our Education team will be in touch with you to discuss the next steps.

FOR ADDITIONAL INFOMRATION ABOUT OUR OTHER PROGRAMS PLEASE VISIT PCUL.ORG/EDUCATION OR CONTACT THE YOUTH & FAMILY SERVICES DEPARTMENTAT 727-327-2081 OR EMAIL EDUCATION@PCUL.ORG.

Thank you!

PARENT/GUARDIAN AUTHORIZATION TO RELEASE INFORMATION

PHOTO/VIDEO RELEASE

MEDICAL CONSENT