Dr. Harold Guinyard Leadership Academy Application
Please have both the child and parent/guardian complete their respective sections to apply. For more information about the Leadership Academy, visit www.100BlackMenSF.org
Child's First Name *
Your answer
Child's Last Name *
Your answer
Child's birthdate *
MM
/
DD
/
YYYY
Child's street address *
Your answer
Child's city *
Your answer
Child's zip code *
Your answer
Child's phone number
Your answer
Child's email address
Your answer
Child's school name *
Your answer
Child's grade level *
Unweighted cumulative GPA *
Or describe the types of grades the child receives
Your answer
Any medication condition or medication requirement? *
Describe any medical conditions
Your answer
Child's shirt size *
Child's section
Please have the child complete these questions
List ALL school, church, and community involvement activities *
Your answer
Why do you want to become a member of the Leadership Academy? *
Your answer
What do you want to do in life or be when you grow up? *
Your answer
Parents/Guardians
Primary parent/guardian's name *
Your answer
Primary parent/guardian's phone number *
Your answer
Primary parent/guardian email address *
Your answer
Primary parent/guardian address *
Your answer
Parent/guardian #2 name
Your answer
Parent/guardian #2 phone number
Your answer
Parent/guardian #2 email address
Your answer
Emergency contact name *
Your answer
Emergency contact number *
Your answer
Please indicate the child's family structure *
Check all that apply
Required
Number of brothers
Your answer
Number of sisters
Your answer
Household Income
Is the child on free and reduced lunch? *
Why do you want your child to become a member of the Leadership Academy? *
Your answer
How did you learn about the Leadership Academy and/or who referred you? *
Your answer
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