Yes, M.I.S.S. Inc. Participant Application

Yes, M.I.S.S. Inc. (Motivate Innovate Support Succeed) is a 501(c)(3) organization dedicated to empowering young women aged 14-18 from underserved backgrounds in Northern New Jersey that aims to equip and empower young women in middle and high school with the tools and support to pursue their God-given purpose in the marketplace and their communities. Our mission is to provide comprehensive postsecondary and workforce readiness support through targeted education and skill training programs. We achieve our goals by forging strategic partnerships with colleges, trade programs, and prominent corporations. Through initiatives such as college immersion days, work site visits, job shadows, and professional development workshops, we equip our participants with the knowledge, skills, and opportunities necessary to succeed in higher education and the workforce.

This application is required for your child to participate in Yes, M.I.S.S. Inc. events. Please note parents/guardians will have to give written consent for your child to participate in field trips as they are scheduled. 

If you live outside of these three counties, parents/caregivers will need to transport their daughter to one of these counties for events, etc.

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Participants First and Last Name *
Participant Date of Birth *
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Participant School Name *
Participant Current Grade *
Participant Address (City, State, Zip Code) *
Participant Cell Phone Number *
Participant Email Address *
DEMOGRAPHIC INFORMATION
Participant Race/Ethnicity
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Language(s) spoken at home
What career path(s) are you interested in?
What goals would you like this program to help you achieve?
PARENT/GUARDIAN INFORMATION
Primary Parent Full Name *
Primary Parent Personal Cell Phone Number *
Primary Parent Address if different than address listed above *
Primary Parent Email Address *
Secondary Parent Full Name *
Secondary Parent Cell Phone Number *
Secondary Parent Email Address
Secondary Parent Home Address if different than address listed above *
EMERGENCY CONTACT INFORMATION
Emergency contact will only be notified in the event that primary/secondary could not be reached after several attempts. 
Emergency Contact Full Name  *
Emergency Contact Cell Phone Number *
Emergency Contact Address 
MEDICAL INFORMATION
Primary Dr. Name and Phone Number *
Medications *
Known allergies or reactions *
Any thing else we should know about you/ your child? *
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