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Saturday Leadership Academy (SLA) Student Registration Form - 100 Black Men of Greater Washington D.C.
THANK YOU FOR YOUR INTEREST: Please read all instructions carefully. Parents or Guardians shall complete one form for each child they wish to register in SLA. Please send all questions about SLA to
mentoring@100blackmendc.org
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Student's First Name
*
Your answer
Student's Last Name
*
Your answer
Street Address
*
Your answer
City
*
Your answer
State
*
District of Columbia
Maryland
Virginia
Other:
Zip Code
*
Your answer
Ward
Choose
Ward 1
Ward 2
Ward 3
Ward 4
Ward 5
Ward 6
Ward 7
Ward 8
Student mobile phone number
*
Your answer
Student home phone number
Your answer
Student email address
*
Your answer
Student Age
*
Your answer
Student Date of Birth
*
MM
/
DD
/
YYYY
School Name
*
Your answer
School Type
*
Public
Charter
Private
Home school
Other:
Current grade level
*
Choose
6
7
8
9
10
11
12
Please select favorite subjects
English/Reading
Math
Science
History
Technology
Physical Education
Music
Foreign Language
Date of most recent report card (approximate)
*
MM
/
DD
/
YYYY
Most recent report card grade in: Math (enter a numeric grade)
*
Your answer
Most recent report card grade in: English (enter a numeric grade)
*
Your answer
Most recent report card grade in: Science (enter a numeric grade)
*
Your answer
Please enter at least two hobbies or interests
Your answer
Please enter recent extracurricular activities (sports, after-school clubs)
Your answer
Does the participant have a part-time job?
Yes
No
Clear selection
Parent-Guardian First Name
*
Your answer
Parent-Guardian Last Name
*
Your answer
Parent-Guardian Phone Number
*
Your answer
Parent-Guardian email address
*
Your answer
Has the child ever participated in a program sponsored by the 100 Black Men of Greater Washington DC?
*
Yes
No
Not sure
How do you hope our program will benefit the participant?
*
Your answer
Will the participant have access to a computer during our (remote) sessions?
*
Yes
No
Will the participant have internet access?
*
Yes
No
Does the participant plan to enter college within the next two years?
*
Yes
No
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