IGNITE 2018 Program Application
Please complete and submit this application along with all required documents for Urban Restoration Enhancement Corporation's 2018 IGNITE Fellowship program.

- Completed application
- Current high school transcript (attach/upload via this application)
- Copy of parent(s)/guardian 2017 Income Tax Return OR a copy of the last three paycheck stubs (attach/upload via this application)

Entrepreneurship Boot-camp
(July 16th - August 3rd)

ACT Prep & College and Career Readiness
(September 4th - November 17)

Students are required to participate in both components in order to complete the program.

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 rvalverde@urecbr.com.

Student's First Name *
Student's Last Name *
Student's Date of Birth *
Gender *
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 - Home *
Phone - 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. *
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 *
Gross Monthly Income *
Total Number of Individuals in Household *
A GPA of 2.0 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:
List any of your child's previous teamwork or leadership experience. *
Use the space below to share any additional information.
How did you hear about this institute? Check all that apply. *
Attach/Upload Most Recent Transcript *
Attach/Upload Income Documents (Copy of parent(s)/guardian 2017 Income Tax OR a copy of the last three paycheck stubs) *
(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 *
Student Signature: (The student will sign this application by typing his/her name below). *
Student - Indicate Today's Date *
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