IGNITE 2019 Program Application
Please complete and submit this application along with all required documents for Urban Restoration Enhancement Corporation's 2019 IGNITE Fellowship.

REQUIRED DOCUMENTS:
- Completed application
- Current high school transcript (attach/upload via this application)
- Copy of parent(s)/guardian 2018 Income Tax Return OR a copy of the last three paycheck stubs (attach/upload via this application)

PROGRAM DATES
Entrepreneurship Boot Camp
(June 19th – July 31st)
Monday - Friday, during the day

ACT Prep & College and Career Readiness
(September 3rd – November 13th)
Monday - Friday, after school

ABOUT UREC
Urban Restoration Enhancement Corporation’s College and Career Ready Initiative is a 21st Century Community Learning Center that provides afterschool and summer learning programs with the support of sponsors. Institutes include the: ACT and College Admissions Prep Institute; Pre-Law Institute; Emergency Medical Responder Institute; and IGNITE Fellowship & Entrepreneurship Institute with a paid internship. Learn more at www.urecbr.com.

For more info about he IGNITE Fellowship, call 225-356-8871 or email info@urecbr.com.

Student's First Name *
Student's Last Name *
Student's Date of Birth *
MM
/
DD
/
YYYY
Gender *
Required
School Name
Grade (for current 2018-2019 school year)
Parent/Guardian's First Name *
Parent/Guardian's Last Name *
Address Line 1 *
City *
State *
Zip Code *
Email Address- Student *
Cell Phone - Student
Email Address - Parent/Guardian *
Phone - Parent/Guardian (Home) *
Phone - Parent/Guardian (Cell) *
Phone - Work
Emergency Contact 1 - First & Last Name *
Emergency Contact 1 - Relation to Child *
Emergency Contact 1 - Phone # *
Emergency Contact 2 - First & Last Name *
Emergency Contact 2 - Relation to Child *
Emergency Contact 2 - Phone # *
No transportation available to or from Southern University. Check all that apply. *
Required
Please list the names of other individuals approved to pick up your child. A valid driver's license must be presented to pick up students. *
Indicate the type of lunch your child receives: *
Family Type *
Total Number of Individuals in Household *
Please list the first and last names of all individuals in the household who are 18 years or older.
Gross Monthly Income (Please include income from all individuals in the household who are 18 year or older.) *
A GPA of 2.5 or higher is required for acceptance into the IGNITE Fellowship. List your child's most current GPA: *
Have you and your child discussed his/her interest in a particular college, career, or course of study after high school? If yes, please indicate your child's interests. *
Has your child taken the ACT? *
If your child has taken the ACT, please list ACT score:
How did you hear about this program? Check all that apply. *
Required
Attach/Upload Most Recent Transcript *
Required
Attach/Upload Income Documents (Copy of 2018 Income Tax OR a copy of the last three paycheck stubs from parent(s)/guardian(s) AND all other individuals in household 18 years or older) *
Required
(Permission Statement): I give permission for my child to participate in the College & Career Ready Initiative's IGNITE Fellowship. I understand that to participate in the institute: (1) The student will be required to pass a background check and drug screening (all required notices will be provided at time of rendering); (2) We must submit the student’s final, year-end report card and information from the student’s math and ELA teachers (this information will remain confidential and will only be used for program reporting purposes); and (3) The student must maintain regular, on-time attendance (with the exceptions of illness or family emergencies). I pledge to work with my child and encourage his/her attendance and active participation. I certify that by entering my name in the box, the information given herein is complete true and accurate. *
Today's Date *
MM
/
DD
/
YYYY
Student Signature: (The student will sign this application by typing his/her name below). *
Student - Indicate Today's Date *
MM
/
DD
/
YYYY
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service