Name: Mission Empower Monthly Webinar – November 15, 2019
Start: 2019-11-15T12:00:00-05:00
End: 2019-11-15T13:00:00-05:00
Location: Mission Empower

Information Release and Signature (To Be Completed by Parent/Guardian)
If you are 18 or older, please complete the following information with your name in the Youth and Parent/Guardian fields.
Youth's Name*
First Last
Today's Date*
Date Format: MM slash DD slash YYYY
I hereby grant permission for Mission Empower to make contact with my child and conduct a personal interview for the purposes of applying to be in the Youth Envision Program.

We encourage parents to attend the interview with their child. Please provide a time & day of the week that works best for you.
Example: M/W/F 3-4pm*
I understand that basic information about my child will be kept private in accordance with HIPPA privacy laws. By signing below, I verify all information listed on this application is accurate.
Parent/Guardian Signature*
Today's Date*
Date Format: MM slash DD slash YYYY
We look forward to contacting you to set up an interview with you!

Please be aware that submitting this application does NOT guarantee you a spot at the Summer Youth Summit. ALL applicants will be interviewed, screened, and given final consideration regarding their eligibility to join the program by the Youth Envision program coordinator(s) and Mission Empower's executive director. We thank all applicants for their interest in the program.
CAPTCHA

Youth ENVISION - Youth Application

Step 1 of 3

Student Demographic Information

Parent/Guardian Information

Emergency Contact Information

Application Questions (To Be Completed By Youth)

By signing below, I verify all information listed on this application is accurate, and that I will commit to my participation in the Youth Envision Program.

Information Release and Signature (To Be Completed by Parent/Guardian)

I understand that basic information about my child will be kept private in accordance with HIPPA privacy laws. By signing below, I verify all information listed on this application is accurate.

We look forward to contacting you to set up an interview with you!

Mission Empower Monthly Webinar – September 20, 2019

IEP Trainings and Clinic

Mission Empower Monthly Webinar – October 18, 2019

Mission Empower Monthly Webinar – November 15, 2019