"Little Leaders" Leadership Sessions Registration and Permission Form
HeartSmiles is excited to partner with YOU and your 5th grader, the Johns Hopkins Bloomberg School of Public Health, Center of Adolescent Health, Bloomberg Philanthropies and other organizations to bring project opportunities that allow youth to network, learn and demonstrate leadership skills and earn extra money.

This project is especially unique because the facilitators are high school mentors, HeartSmiles' Heartbeats who have demonstrated exceptional leadership skills and are passionate about giving back and sharing what they've learned on their growth journey with younger youth.

These leadership sessions are a great way to build your child's capacity as a leader, work with older students who have been where they are AND secure MORE opportunities where they can earn money while learning about leadership.

To be eligible for participation You MUST have these qualities:

- Willingness to learn about leadership
- Able to attend all sessions (sessions are on Wednesdays, 3:30pm-4:30pm starting April 14th thru June 9th)

If at any time your child is not showing up or not being open to learn, they will be dismissed from the leadership sessions. Our goal is to give this opportunity to those who want it.

What your child will gain from this opportunity:

- Learn what it takes to be a strong leader
- Learn how they can become a positive role model for their peers
- Your child will earn $10 for each session they attend up to $100 plus extra incentives including care packages and other helpful benefits

Contact us with any questions and keep in mind space is extremely limited.

email: HeartSmilesMD@gmail.com DM: HeartSmilesMD Call\Text: Ms. Mo 443-244-5816 or Ms. Joni 443-271-4075

*This form should be completed by a parent or legal guardian. By completing you are granting permission for your child to participate in the HeartSmiles Leadership Program for 5th graders. You are also granting permission for your child's picture\images to be used for marketing and promotion by HeartSmiles and it's partners. If you do not agree please do not complete this form*
Sign in to Google to save your progress. Learn more
Email *
Student's email address (one you and\or student checks often) *
Student's Cell Phone Number *
Student's First Name *
Student's Last Name *
Age *
What School does your child attend? *
What is the school address? *
Grade? *
Parent First Name *
Parent Last Name *
Parent email address *
Parent phone number *
Student's Primary Home Address (care packages may be delivered to this address) *
City *
State *
Zip Code *
Student's Instagram name *
Emergency Contact (Full Name & Reliable Number) *
Please list any allergies we should be aware of *
Who referred you to this program *
Why does your student want to participate in this program? (please ask and type their answer) *
Is your student able to attend ALL Sessions? (Sessions will be held on Wednesdays, 3:30pm-4:30pm on zoom. Sessions Start on April 14th and end June 9th) *
What is the preferred method for your child to receive their payment? (check all that apply) *
Please list your handles for cashapp, PayPal, Venmo in order of your preference *
Is there anything you or your student would like us to know regarding their participation? *
Is there anything you or your student would like us to know regarding their participation? *
How do you connect with HeartSmiles? (check all that apply) *
By Completing this form I acknowledge that I am the parent and\or legal guardian, I grant my child permission to fully participate, I grant HeartSmiles and it's partners to use my child's pictures\videos for marketing, promoting, ect, I will not hold HeartSmiles or it's partners liable for any injuries due to participation, HeartSmiles and it's partners will comply with the latest guidance from the CDC and City of Baltimore as it relates to COVID-19. *
A copy of your responses will be emailed to the address you provided.
Clear form
Never submit passwords through Google Forms.
This form was created inside of Leading 4 Longevity. Report Abuse