PDDBM Afterschool Program Application Form
Student Information: The information on this application will be kept confidential. It will be used to determine eligibility for Please Don't Die Black Men's (PDDBM) Afterschool Programs. Some of the general information entered below will be used as statistics to apply for grants and other funding for our afterschool programs.

It will take approximately 5 - 10 minutes to complete.

Please check "None" or put "N/A" for all questions that do not apply.

Program Cost
The cost of all Please Don't Die Black Men (PDDBM) afterschool programs for middle and high schoolers is free for low-income and vulnerable students. All other students above the household income eligibility guidelines must pay a one time fee of $350 per school year per program or $35/month for 10 months (regardless of time of enrollment). Guidelines are based off of the 2024 HHS Poverty Guidelines for Clark County.

Complete this application to determine your student's eligibility.

Location
To Be Determined

Program Run Time
All afterschool programs will run after school during the academic school year.

Questions and/or comments
Please direct any and all questions about this form or about PDDBM Afterschool programs to the PDDBM Chairwoman and President, Ruby N Lewis, CEOCHAIR@PDDBM.ORG, (360) 241 - 4479.

Completion of This Form
This form can be completed online (https://forms.gle/jJ7wi8FGZawtU6w48) or can be printed out and mailed to: 

Please Don't Die Black Men (PDDBM)
2700 Caples Avenue #3278
Vancouver, WA 98661
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Email *
Student's Name (Last Name, First Name, MI) *
DOB (MM/DD/YYYY) *
MM
/
DD
/
YYYY
Age *
Gender *
Ethnicity *
Current Grade in School (Select the grade that the student is currently enrolled in/will be enrolled in for the 2024 - 2025 school year.) *
Which Type of School is the Student Currently Enrolled In/Will Be Enrolled In for the 2024 - 2025 School Year? (Check All That Apply) *
Required
Current School Attending (List the complete name of the school the student is currently enrolled in for the 2024 - 2025 School Year.) *
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