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Youth Empowered to Explore 2022 Application
Indianapolis youth summer sailing trip to Baltimore, MD.
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Email
*
Your email
Are you the parent or legal guardian of the child you are completing this application for?
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Yes
No
Parent/Guardian Name
Your answer
Parent's cell phone number
*
Your answer
Youth First Name
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Your answer
Youth Middle Name
*
Your answer
Youth Last Name
*
Your answer
Address
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Your answer
City
*
Your answer
State
*
Your answer
Zip Code
*
Your answer
Country
*
Your answer
Race
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American Indian, Alaskan Native or other Indigenous Person
Asian
Black/African American
European American (White)
Native Hawaiian or Other Pacific Islander
Multiethnic Identity
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Other:
How would your child identify their self?
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Female
Male
Nonbinary
Prefer Not to Say
Other:
Date of Birth
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MM
/
DD
/
YYYY
Age
*
Your answer
Height
*
Your answer
Weight
*
Your answer
What school will your child attend in the 2022-2023 school year?
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Your answer
Grade in School 2022-2023 school year
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6th
7th
8th
9th
Describe how your youth would benefit from participating in Maritime Education Weeks.
Your answer
Please describe your child's academic performance.
Your answer
Please describe your child's learning style.
Your answer
What primary language does your child speak at home?
*
Your answer
Has your child had any school disciplinary issues?
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Yes
No
If you answered yes to the previous question, please describe the circumstances.
Your answer
Has your child had any interaction with the court system?
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Yes
No
If you answered yes to the previous question, please describe the circumstances.
Your answer
Sailing Experience
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Beginner
Intermediate
Experienced
Shirt Size
*
Youth XS
Youth S
Youth M
Youth L
Adult S
Adult M
Adult L
Adult XL
Adult XXL
Adult XXXL
Shoe Size
Your answer
Did the youth participate in our sailing program last year?
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Yes
No
How did you hear about Youth Empowered?
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Your answer
Does your child have any disability or accommodation needs?
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Yes
No
Please describe the child’s diagnosis, signs and symptoms, required care and medicinal use.
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Your answer
Does the sailor have any other medical conditions that we need to be aware of?
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Yes
No
Please describe the medical conditions and the prescribed treatments.
*
Your answer
Are there any additional details about your child’s health that staff should be aware of or an attending doctor should know? Please describe.
Your answer
Is there anything else that you or your child wants the staff to know about your child (e.g., any learning challenges, religious preferences, name preferences, etc?
Your answer
What is your family income level?
*
Less than $20,000
Less than $40,000
Less than $60,000
Less than $80,000
Less than $100,000
$100,000 or above
Parent/Legal Guardian Highest Education Level
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High School
Trade School
Some College
Bachelor's Degree
Master's Degree
Doctoral Degree
Consent & Release
*
I understand that this application is not an offer of acceptance to the program.
I understand that a background check of the parents/guardians may be performed.
I understand that if accepted, my child must comply with all rules or they may be dismissed.
I understand that I may be contacted for additional information.
I understand that acceptance is contingent upon availability of program spaces and completion of the application process in its entirety
I understand that mine or my child's image and likeness may be recorded and shared in organizational mediums
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