Supplemental Application Form – Guyanese Girls Rock Foundation

SECTION 1: PERSONAL INFORMATION

Thank you for your interest in applying to the Guyanese Girls Rock Young Women's Leadership Academy (YWLA). Please complete and submit the application form below. CLICK HERE to review program details.

Full Name of Applicant & Applicant's Nickname

First

Last

Date of Birth

Email Address

Phone

Grade

Current Home Address. Please include full address.

Address Line 1

Address Line 2

City

State

Zip Code

Were you born in Guyana?

If not, please share briefly your family background as it relates to Guyana.

What job/career do you envision yourself in when you finish college?

Do you have a special interest, talent or hobby?

E.g. Art, Dance, Sports, Technology, etc.

If you answered yes to the above question, are you part of a program?

If yes, is this a paid program?

THIS SECTION MUST BE COMPLETED BY APPLICANTS

We are so excited that you’re interested in being a part of the Young Women's Leadership Academy. We want to make this the best possible experience for you and the other participants in the program. We’re asking the questions below to get to know you better. We would like you to complete the questions below without help from an adult. We really only want to hear from you. There aren’t any “right”or “wrong” answers; just be yourself and let us know who you are.

Why do you want to be a part of the YWLA Program?

What does a leader look like to you? Name one person who you consider to be a great leader.

What about your school do you like? What do you find challenging?

Tell us something that you’ve done that you are proud of.

What social issue(s) if any, have you struggled with? For example, bully, low self esteem, peer pressure, etc.

Do you have any special skills, talents, interest or hobbies? For example, arts, dance, music, etc.

SECTION 3

Name

First

Last

Email

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Does your daughter have any physical problems or limitations? (Yes or No). If yes, please explain.

Is your daughter currently receiving treatment for any medical condition or other challenges? (Yes or No) If yes, please explain.

Ia your daughter currently taking any medication? (Yes or No) If yes, please explain.

Does your daughter have any known allergies or adverse reactions to medications (Yes or No). If yes, please explain.

Does your child have access to computer equipment and reliable internet service?

Participants are required to attend classes via zoom and must turn on their cameras.

If you answered yes to the above question, was this equipment/service provided/paid for by the Department of Education?

Participants are required to attend classes via zoom and must turn on their cameras.

If you answered "No" to the above question, do you need assistance with obtaining access to computer equipment and reliable internet service?

Participants are required to attend classes via zoom and must turn on their cameras.

Parent/Guardian Name

First

Last

Date / Time

Date

Time

Signature

Clear Signature

By signing and submitting this Application, I certify that the above information is correct and complete. Please use your mouse (or finger on mobile devices) to create signature.