100 Black Men of Dekalb

Let’s begin with the parent or guardian information we will use to communicate about this application.

Section 1: Family / Parent Information

Parent / Guardian First Name *

Parent / Guardian Last Name *

Email Address *

Phone Number *

Street Address *

City *

State *

ZIP Code *

Relationship to Youth *

Preferred Contact Method *

Email Phone Text

This application is for students in 8th grade and above. Tell us about the young person who is applying.

Section 2: Youth Information

Youth First Name *

Youth Last Name *

Date of Birth *

Age *

Gender *

Current Grade / School Year *

Expected Graduation Year

T-Shirt Size

Current School Name *

Share the programs, goals, and interests that will help us connect your child with the right opportunities.

Section 3: Program Interest *

Section 4: Academic Background

Current GPA (if applicable)

Academic Standing *

Academic Goals & Aspirations

Academic or Personal Challenges (optional)

Section 5: Extracurricular Activities & Interests

Select all that apply

Sports / Athletics Music / Band / Choir Visual Art / Drama Community Service / Volunteering Student Government / Leadership STEM / Robotics / Coding Club None currently

Other Hobbies or Interests

This information helps us support your child safely and appropriately.

Section 6: Family Background

Household Size *

Household Income Range

Family Background / Additional Context (optional)

Section 7: Emergency Contact

Emergency Contact Name *

Emergency Contact Phone *

Relationship to Youth *

Section 8: Health & Medical Information

Does your child have any medical conditions, allergies, or disabilities we should be aware of? *

No Yes

Primary Care Physician Name (optional)

Physician Phone (optional)

Review the final agreements and add any details that will help our team follow up.

Section 9: Consent & Agreements *

I consent to my child participating in 100 Black Men of DeKalb County programs and activities. * I consent to my child being photographed or recorded for program documentation and promotional use. I authorize emergency medical treatment if I cannot be reached. * I certify that all information provided in this application is accurate and complete. *

Does the youth reside in DeKalb County? *

Yes No

Yes, I would like to receive occasional email updates from 100 Black Men of DeKalb County about programs, events, and opportunities. I understand that I may unsubscribe at any time.

Parent / Guardian Signature (Type full name) *

Date *

Section 10: How Did You Hear About Us?

Social Media (Facebook, Instagram, etc.) School / Teacher / Counselor Friend or Family Member Community Event Church / Faith Organization Website / Internet Search Other

Section 11: Additional Comments

Is there anything else you would like us to know?

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