2023-2024 PROJECT MALE STUDENT REGISTRATION FORM

August 28, 2023

Greetings:

Project MALE's (Making Aspirating Leaders Excel) Program Year is October - May. To register a student for Project MALE for Program Year 2023 - 2024, please complete the attached form. Please answer ALL questions. If the question does NOT APPLY to you or your child, write NA in the box.

By registering a student, you agree that the student will:

-- Be in attendance and on time for each session.

-- Be prepared for each session.

-- Follow instructions and will be on best behavior during sessions.

By registering the student, you agree that you will attend the activities with the student whenever possible.

If you have questions or need further clarification, please reach out to either of the persons listed below.

Thank you for your interest in Project MALE.

PROJECT MALE PLANNING COMMITTEE MEMBERS:

Dr. Jennifer Wimbish, jbwimbish@yahoo.com, 469-826-9108

Carole Mayo, clmayo44@yahoo.com, 972-386-0596

(Note: Project MALE also partners with the EMBODI group of the Dallas Alumnae Chapter of Delta Sigma Theta Sorority.)

Question Title

* 1. Today's Date

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* 2. Student's Name (First and last)

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* 3. Student's Home Address:

Street Address

City

State

Zip Code

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* 4. For Child #1, please give...:

Student's Date of Birth (Month, Day, Year)

Grade

Age

School Attending

Church Affiliation

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* 5. For Child #2, please give...:

Student's Name

Date of Birth (Month, Day, Year)

Grade

Age

School Attending

Church Affiliation

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* 6. Parent's/Guardian's Information:

Parent's/Guardian's Name

Relationship

Home Phone

Cell Phone

Email Address

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* 7. EMERGENCY PICK UP AUTHORIZATION: I authorize the person listed below to pick up my child from the Project MALE Program. For my child's safety, I understand that any authorized person on the list below will be asked to show photo identification before my child is released to them; therefore, I will notify all authorized persons of this requirement so that they will have photo identification with them when they arrive to pick up my child.

Name

Relationship

Home Phone Number

Cell Phone Number

Work Phone Number

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* 8. Is there anything else you wish to add?

Yes

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