LOT Student Application | NBMBAA Charlotte

NBMBAA Charlotte Chapter LOT Student Application

This form should be completed by the applicant/student, not the parent/guardian. Submit this form and the Counselor’s Report. Thank you for your interest in NBMBAA Charlotte Chapter Leaders of Tomorrow (LOT) Program.

Last name

First name

Middle Name

Birthday

Applicant's Phone Number & Address

Cell Phone

Home Phone

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Parent/Guardian Information

Last Name

First Name

Email Address

Relationship of Student to Parent/Guardian

Phone Number

Student Emergency Contact Information

Last Name

First Name

Email Address

Relationship of Student to Emergency Contact

Phone Number

Allergy Information

Please list any allergies, to include food allergies, or medical conditions or type “N/A” if none.

Applicant School Information

School Name

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

GPA

Current HS Grade Level

Short Answer Questions

1. Why do you want to join Leaders of Tomorrow?

2. List your extracurricular activities, to include community service/volunteer projects (school and non-school related):

2a. Will you be able to commit to the NBMBAA Charlotte LOT Program in addition to your other extracurricular activities?

Yes

2b. Does any of your other activities conflict with the NBMBAA Charlotte LOT meeting schedule?

Yes

3. How do you currently demonstrate leadership within your school or community?

4. Do you take Honors/AP/IB Classes? If so, list the classes. If not, please type "N/A".

5. List any subjects in which you may need additional academic support.

6. What professional skills are you interested in developing (ie. Networking, Public Speaking, Leadership…)?

7. Do you plan to attend college immediately upon graduating high school? If not, what are your career plans?

8. What are your career goals?

9. List colleges/universities in which you are interested in applying and major that you intend to pursue in college.

Your Signature

Parent/Guardian Signature

Date Signed

STUDENT AND PARENT/GUARDIAN CONSENT AND RELEASE FORM

Print Name of Student (First, Middle, Last):

I am the parent or legal guardian of the student listed above (“son” or “daughter”), and he/she has my permission to participate in the NBMBAA Charlotte Leaders of Tomorrow® Leadership Program.

EMERGENCY CARE AUTHORIZATION

In the event that I am unable to be reached in an emergency situation, as parent/guardian, I delegate authority to the representatives or mentors of the National Black MBA Association, Inc. and the Charlotte Chapter of the National Black MBA Association to act in my absence to assure that my son/daughter will receive emergency medical care if the need arises. This includes any medical personnel and facilities involved in such care.

WAIVER AND RELEASE OF ALL CLAIMS AND ASSUMPTION OF RISK

Please read this form carefully and be aware that in signing up and participating in Leaders of Tomorrow program/activities, you will be expressly assuming the risk and legal liability and waiving and releasing all claims for injuries, damages or loss which you or your minor child/ward might sustain as a result of participating in any and all activities connected with and associated with NBMBAA Charlotte Chapter programs/activities (including transportation services/vehicle operation, when provided). I recognize and acknowledge that there may be certain risks involved in participating in programs/activities, and I voluntarily agree to assume the full risk of any injuries, damages or loss, that my minor child/ward or I may sustain as a result of said participation. I further agree to waive and relinquish all claims I or my minor child/ward may have (or accrue to me or my child/ward) as a result of participating in such program/activity against NBMBAA Charlotte Chapter, including their respective officials, officers, employees, and volunteers (hereinafter collectively referred as “Parties”). I do hereby fully release and forever discharge the Parties from any and all claims for injuries, damages, or loss that my minor child/ward or I may have or which may accrue to me or my minor child/ward and arising out of, connected with, or in any way associated with these programs/activities. I indemnify and hold harmless NBMBAA Charlotte Chapter, including their respective officials, officers, employees, and volunteers from any and all claims from my use of NBMBAA Charlotte Chapter property or participation in any programs. I will further indemnify and “hold harmless” NBMBAA Charlotte Chapter, including their respective officials, officers, employees, and volunteers from all costs, expenses and liabilities resulting from any claim brought from my child’s/children’s use of NBMBAA Charlotte Chapter property and/or participation in programs to the extent of the NBMBAA Charlotte Chapter’s liability under general law.
This is to certify that I, as parent/guardian with legal responsibility for this participant, do consent and agree to his/her release as provided above and, for myself, my heirs, assigns, and my minor child’s involvement or participation in the program as provided above.

I hereby grant permission for myself or my child to be photographed or recorded in connection with any NBMBAA Leaders of Tomorrow promotion. I understand that any photographs or other types of media production may be used for promotional purposes and shown to the general public.

COLLEGE SCHOLARSHIP FUNDS
I acknowledge that any funds awarded to my son/daughter as a result of his/her participation in the Leaders of Tomorrow® Leadership Program are scholarship funds to be used solely for educational purposes. Any scholarships awarded will be made payable and mailed directly to the educational institution. Program participation does not guarantee a scholarship award. It is at the sole discretion of
the NBMBAA and NBMBAA Charlotte Chapter.

Your Signature

Parent/Guardian Signature

Date Signed

Thanks for submitting!