Boys Leadership Program

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The vision of the Male Initiative program is to equip young men with tangible skills and knowledge that develop them into role models and leaders within their homes, communities and jobs. Activities will promote young men to become men of excellent work ethic and obtain a high moral character.

Please complete this form if you are interested in participating in the Girls/Boys Leadership Program.

Email *

Last Name *

First Name *

What is your email address? *

What is your home address? *

What City do you live in? *

What is your Zip Code *

What is your phone number? *

Grade Level (Fall 2021) *

Date of Birth *

YYYY

T-Shirt Size? *

XXL

What school will you attend fall 2021? *

What school district is this school in? *

What are your hobbies? *

Parent Name *

Parent Email *

Parent Cell Phone Number *

Name of Emergency Contact *

Emergency Contact Phone Number *

I understand that my signature and my parent/guardian signature authorize STEM BRIDGES Houston representatives and/or the news media to photograph, videotape, audiotape, duplicate and transfer to any present or future technology their images while they are scholars, featured subjects or participants in STEM BRIDGES Houston programs. Authorized agents and news media may use the photographs, videotapes, and audiotapes as appropriate to promote the STEM BRIDGES Houston and related programs. No compensation will be paid for this use. I certify that the information reported on this application is true, complete, and accurate to the best of my knowledge. *

Yes

I understand that my signature and my parent/guardian signature means that I will ctively participate in the activities and events for the Girls Leadership Program. *

Yes

I was recommended for the leadership program by_________________ (Please write full name) *

Student Electronic Signature *

Parent Electronic Signature *

Send me a copy of my responses.

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