Brown Girl Dreams Member Application

Brown Girl Dreams Member Application

Thank you for your interest in being in the 2015-2016 Brown Girl Dreams (BGD) class. We are delighted to have you and we look forward to you becoming selected as a Dream Girl. A Dream Girl is an amazing young lady, radiating with enthusiasm to find her passion, while engaging in her community for positive change! This year's BGD Program will be held August 2015-May 2016. The Dream Girls will participate in two session per month, as well as weekend community service days and/or field lessons. Please complete all the information below, and solicit the aid of your parent/guardian to ensure its full completion.
Full Name

First Name Middle Name Last Name
Date of Birth

Month Day Year

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Home Number

- Area Code Phone Number
Cell Number

- Area Code Phone Number
E-mail
Ethnicity

Asian-American Hispanic African American Caucasion
Language
Social Media

If you have an account with any of the following social media sites, please provide your usernames.
Facebook
Twitter
Instagram
Vine
Parental Information
Parent/Guardian's Name

First Name Last Name
Parent/Guardian's Home Number

- Area Code Phone Number
Parent/Guardian's Mobile Number

- Area Code Phone Number
Parent/Guardian's Email
Parent/Guardian's Occupation and Current Place of Employment

Parent/Guardian's Current Employment Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Will you be able to provide adequate, timely transportation available to bring your child to and from each session, special events and field trips?

Yes No
Household Information
Select the type of household you live in

Two Parent House One Parent House Grandparents
Select the number of individuals that reside within your household

Two Three Four Five Six or more
Select your annual household income

Under $20,000 $20,000 - $35,000 $35,000 - $50,000 Above $50,000
Please select "I am a"

U.S Citizen U.S. National Resident alien expecting citizenship by the date of award
Educational Information
Current High School
Grade
Current GPA
Graduation Date

- Month - Day Year
Select Your Level of Difficulty for the Following Subject Areas
English/Language Arts

Very Easy Easy Neutral Difficult Very Difficult
Mathematics

Very Easy Easy Neutral Difficult Very Difficult
Science

Very Easy Easy Neutral Difficult Very Difficult
History

Very Easy Easy Neutral Difficult Very Difficult
Physical Education

Very Easy Easy Neutral Difficult Very Difficult
Please list all Extracurricular Activities
Please describe in detail any life changing experiences which have altered you physically, mentally, emotionally, or socially. (Ex. loss of a loved one, assault, parent losing job, relocations etc.)
Essay Questions
Why YOU? Please explain throughly why you should be selected as a Dream Girl.

0/300
Why NOW? Please explain your readiness to make positive changes in your life.

0/300
Parental/Applicant Consent
Signature of Applicant

Clear
Signature of Parent/Guardian

Clear
Should be Empty:

Brown Girl Dreams Member Application

Social Media

Parental Information

Household Information

Educational Information

Select Your Level of Difficulty for the Following Subject Areas

Essay Questions

Parental/Applicant Consent