Pledge High Five Movement
As a Member of the Pledge Five Movement, you promise to take the Pledge to Respect Everyone, Love Everyone, Actively Listen to Everyone, Adopt a healthy life style, Go to school and complete my education, Give back to my community, Love my country and Love Mother Earth. Are you willing to take this pledge today ? *
What is your Name *
First name, Last Name
Your answer
What year were you born ? *
Your answer
What is your dream ? *
If money was not a problem what would you like to do in life ?
Your answer
Your primary phone number
(Optional Question)
Your answer
Any additional phone numbers - For example your home phone number
(Optional Question)
Your answer
Your Email address (if you do not have one, please enter a friend's email address) *
We will NEVER share your email
Your answer
Please reenter your email address *
Your answer
Mailing Address *
This is the address where we will mail you your gift
Your answer
We would like you to do 5 Good Deeds to claim your Cap. Please take a moment to let us know what these five deeds are. *
Take your time - there is no hurry. Examples of Good deeds, Help a friend with his/her studies, Volunteer at a local non for profit, Help an elderly person to clean their garden, Help spread the word about Pledge High Five
Your answer
Level of Education
(Optional Question)
What are you doing now ?
(Optional Question)
If you are a student please let us know the name and address of the school you are attending
(Optional Question)
Your answer
If you are working, please let us know your position and the Company name and address you are working at.
(Optional Question)
Your answer
Would you like help in quitting smoking, drugs or Alcohol ? Please share your worries and what you have tried in the past
We will try our best to help you (Optional Question)
Your answer
Any other comments, suggestions you have to make this Movement a success.
Your answer
We would like you to meet with other Pledge Five Members in your Community once a month to discuss future monthly good deeds you can do, how to plan to achieve your dreams and discuss and figure out solutions to the problems you will encounter. What would be the best day and time for this meeting for you ? *
Your answer
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