Apply to the Meadowbrook Girl Ambassador Program

Girl Ambassador Program

Meadowbrook Application

Academic Year 2023-24

About the Girl Ambassador Program (GAP)

This is a four year workforce development program for Black girls that teaches hybrid skills and prepares them for better paying jobs in technology and professional careers while building self-esteem and self-efficacy by ensuring positive images of Black girls in abundance. This program uses a tiered approach that supports paced learning/development from certified instructors with life experiences and proficiency in software and hardware.

Girl Ambassador Program at Meadowbrook High School

"*" indicates required fields

Step 1 of 5 - Personal

20%

Participants Name*

First Last

Birth Date*

MM slash DD slash YYYY

Email*

Phone*

Alt Phone

Current School*

The participant must attend or about to attend Meadowbrook High School for the 2023-2024 school year. Please do not complete this application if you are not a student at Meadowbrook High School.

School ID Number

Current Grade*

Would you like to register for the Summer Program or Fall Program?*

Summer Program (ends August 4th, 2023)

Fall Program (September 18th, 2023-May 10th, 2024

Returning Participant?*

Yes

For fall sessions you have the choice of attending two days of the week. Please choose the two dates that you can commit to attending for the school year.*

Monday & Wednesday sessions

Tuesday & Thursday sessions

Does the student/ participant qualify for free or reduced lunch? We ask for this information to get a better understanding of the families we serve and to ensure that resources are equitably distributed a.*

Free Lunch

Reduced Lunch

Does not qualify for either

Prefer not to answer

Race/Ethnicity (optional)—Please describe yourself*

(check all that apply)

African American or Black

Caucasian, White Latina or Chicana

Asian or Asian American

Native Hawaiian or other Pacific Islander

Multiracial

Meal Restrictions*

I can eat anything

I'm vegetarian

I'm vegan

Other

T-Shirt Size*

Parent/Guardian Information #1

Relationship to Participant*

Title (Optional)

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Alt Phone

Email*

Parent Guardian Information #2

Relationship to participant*

Name*

First Last

Primary Phone*

Alt Phone (Optional)

Employer

Business Phone

Additional Info to know in the event of an emergency

Has your child’s school identified your child as an English Language Learner?*

Yes

MEDICAL TREATMENT/FIRST AID AUTHORIZATION I grant permission for the administration of First Aid to my child by the staff of Girls For A Change (GFAC), and those transporting my child to and from programs as their judgment deems advisable, and to make the necessary referrals to qualified physicians for treatment of illness or accidents of a more serious nature. I understand I will be promptly notified in the event of any serious illness or accident and prior to any major surgery, except when a delay in such communication would endanger life. In case of medical emergency, I understand that every effort will be made to contact the parent/ guardian of the participant and emergency contact. In the event that I cannot be reached, I hereby give permission to the physicians selected by the adult staff to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery, if deemed necessary for my child. *

Check to Grant Permission*

Allergies to Medications: Please type N/A in the boxes below if your child is not currently taking or allergic to any medications.*

Medications Currently Taking or N/A*

INSURANCE INFORMATION (OPTIONAL)

Policy Holder

Insurance Company

Policy #

Authorized Physician

Office Phone Number

Agreement Form for Transportation

Name*

First Last

Relationship to Participant*

Primary Phone*

Child will be picked up at the school/center at the end of the day*

Yes

Child will walk home alone from school/site*

Yes

Do you consent to field trip transportation?*

I, the undersigned parent or legal guardian, release GFAC, or any other person acting on their behalf, from liability for any bodily injury sustained and loss or damage of any personal article while on the premises or participating in any activity provided by GFAC.

Check to Release GFAC From Liability*

Unless a letter to the contrary is received, GFAC accepts your consent for us to take photos and share them on social media as well as GFAC main website.

Check If You Consent*

Apply for Girl Ambassador Program

What is your average grade in English/Literature?*

Mostly A's

Mostly B's

Mostly C's

Mostly D's

Mostly F's

What is your average grade in Math?*

Mostly A's

Mostly B's

Mostly C's

Mostly D's

Mostly F's

How would you rate your attendance in school?*

I have perfect attendance

I miss 1-2 days a month

I miss 5-10 days a month

I miss weeks of school in one month

What type of academic support do you need?*

Math

Literature

Something Different

What career path are you interested in? You can write "not sure" if you do not know what you want to do as a career choice yet/*

Emergency Contact

Name*

First Last

Relationship to Girl*

Cell Phone*

Media Release*

Sometimes,Girls For A Change may use photos of participants in publicity and marketing materials, such as on the program’s website and social media.

Yes, I give permission to allow photos of my child to be used by Girls For A Change for media and marketing materials.

No, I do not give my permission to allow photos of my child to be used by Girls For A Change media and marketing purposes.

How did you hear about Girls For A Change*

Social Media

News/Newspaper

School

Friend/Family/Co-Worker

Other

Receive occasional reminders via SMS/text?*

Yes, I would like to receive updates and reminders via text/SMS

No, I would like to receive updates and reminders via text/SMS

Signature*

Please sign this application to acknowledge that all information above is true and give your child consent to participate in this program.

Please Solve The Puzzle

Phone

This field is for validation purposes and should be left unchanged.

Girl Ambassador Program

Meadowbrook Application

About the Girl Ambassador Program (GAP)

Girl Ambassador Program at Meadowbrook High School

Parent/Guardian Information #1

Parent Guardian Information #2

Apply for Girl Ambassador Program

Emergency Contact

Additional Information

Find Us on Social Media

The Latest via @GirlsForAChange

Subscribe to Our Newsletter