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
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Child's zip code
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Child's phone number
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Child's email address
Your answer
Child's school name
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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
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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