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Boys to Men Leadership Academy Application
CONNECT TO GREATNESS, INC | Electronic Academy Application

Note: The participant should complete the application. Please answer the following questions as completely as possible. This information will help us to recruit the right coach(es) for you.

INCLUDE A LETTER OF RECOMMENDATION FROM A TEACHER, COACH, COUNSELOR ETC., WITH THIS APPLICATION. Recommendation link: https://docs.google.com/forms/d/1xnpQyKpCnSDL9lvwAeANosGPS1SDGGiPt_SBD-JP_LQ/edit
Today's Date *
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Student's First name *
Student's Last name *
Birthdate *
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Grade *
School name *
Which Program are you applying for? *
Why are you interested in participating in this program *
Street Address *
City *
State *
Zipcode *
Student & Parent Telephone Number
Please enter a telephone number for the parent and youth into this box.
Parent Name *
If you are not living with your mother or father, who is your legal guardian?
Name of Guardian
Guardian Relationship to You
How many brothers do you have? *
Brothers age(s)
How many sisters do you have? *
Sister age(s)
My favorite kind of music is
My favorite television show is
My favorite sport is
My best subject in school is
My worst subject in school is
Do you have any after-school responsibilities? (Yes or No) *
If yes, what are your after-school responsibilities
Describe your special interests and hobbies (e.g. sports, arts & crafts, computers/technology, music, reading, cooking, games, career interests, foreign languages, painting, reading, etc.)
What clubs or groups do you belong to?
What do you like to do most with your free-time?
How could a "coach" help you? *
What do you hope to get out of your coaching relationship? *
What would you like to do with your coach? *
Is there anything that you would like to share with your coach?
AGREEMENT: I agree that I will meet with my coach and/or my group at the times and locations arranged between us. I also agree to notify my coach and/or other adult in-charge if I am unable to make a weekly meeting. By entering my Youth Name and Email address I accept that this my electronic signature for C2G. By entering Parent/Guardian name and Email address I accept this as electronic signature for C2G. I give permission for my son to participate in the Connect to Greatness Boys to Men Leadership Academy program and activities. I understand that my son will be expected to follow the set rules and expectations of the program at all times. (Select YES or NO)
Clear selection
Youth Signature Agreement *
Youth Email Address *
Parent/Guardian Signature Agreement *
Parent/Guardian Email *
Parent/Guardian Email *
I understand that during some activities/discussion, my son may be exposed to discussions that are sensitive. I understand that I am responsible for communicating to the leader and adult-in charge about any needs that my child may have in regards to any activities/discussions. I am confident of his maturity and ability to participate. (Select YES or NO) *
1st Emergency Contact Name *
1st Emergency Contact Number *
2nd Emergency Contact Name *
2nd Emergency Contact Number *
3rd Emergency Contact Name
3rd Emergency Contact Number
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