Social InnovateHER Lead to Impact Program Application

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Thank you for your interest in the Social InnovateHER program. Social InnovateHER is a leadership education program for young women and girls. Our goal is to build life and leadership skills to help prepare you for the world. Please complete the short application by answering the questions below. All student applications require the signature of a parent or legal guardian.

First Name *

Last Name *

Age *

Grade *

School Name *

Student Phone Number *

Student Email *

Parent or Legal Guardian Name *

Parent or Legal Guardian Phone Number *

Parent or Legal Guardian Email *

Street Address *

Apartment Number

City/State/Zip Code *

What interests you in the Social InnovateHER Lead to Impact program? *

What activities are you currently involved in at school or out-of-school? *

Why do you want to be the type of leader that makes a meaningful impact? *

What is your race or ethnicity? (Optional)

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

Native Hawaiian or other Pacific Islander

Other:

Clear selection

By signing this document, I hereby certify that all information contained herein, and all documents and information submitted via my online application materials or via any other form, are true, accurate, and complete to the best of my knowledge. *

Yes

Required

I hereby grant permission to SCG by Design LLC to use photographs and/or videos taken during the course of the Social InnovateHER Lead to Impact program to be used in publications, news releases, online, and in other communications related to the mission of SCG by Design LLC. *

Yes

Required

Student Signature *

Parent Signature *

Submit

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