Girls Leadership Program

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Our mission is to help young girls build self-esteem, develop leadership skills, and recognize the value of community service. Our program provides the opportunity for the girls involved to not only improve themselves but to also improve the world around them. An extensive curriculum includes life skills lessons, activities, STEM in dance.
Please complete this form if you are interested in partcipating 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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