Forms and Applications

W.E.B DUBOIS ACADEMY
DUBOI

Enrollment Application

Student's Full Name

Date of Birth

Current School and Grade

Is this student new to the program?

Parent's Cell Phone and Email

Parent/Guardian Name

Please list TWO Emergency Contacts: For each, please list name, relationship, address, cell phone number and email.

List all people with permission to pick up the student from the Academy Program (18 years of age and over). This person must present a valid photo ID in order to pick up student. Student Pick-Up Information

Check here if student is allowed to walk home (must be over 14 to walk home alone).

Household Characteristics

Ethnicity

Race (select all that apply)

Are you a homeowner?

In which neighborhood is your home?

Please tell us your household size and annual income

Does student's health histoy include:

Measles

Convulsions

German Measles

Diabetes

Mumps

Tuberculosis

Bleeding Disorder

Ear Infections

Chicken Pox

Please list any operations/serious injuries

Please list any medications for physical condition

Please list any allergies including but not limited to: eggs, fish, milk, peanuts, shellfish, soy, tree nuts, wheat

Please list any special circumstances or concerns regarding student

Name of Student's Physican

Name of Student's Dentist

Date of Last Physical Exam

Has student had all required immunizations? If not, please explain

Can your child swim?

Yes

Has student ever had COVID-19 or any of its variants?

Yes

If yes, when did your child have COVID-19?How long did it last? What were the symptoms?

Has student been vaccinated for COVID?

Yes

Do you grant permisson for student to appear in Academy promotional material?

Yes

Do you grant permisson for Academy official to contact student's school on their behalf?

Yes

If yes, when, where and which vaccine did they get?

Do you grant permisson for student to be transported by Academy officials to functions taking place off campus?

Yes

Would you be willing to participate in meetings/workshops for parents/guardians?

Yes

Most recent report card.

Upload supported file (Max 15MB)

Most recent physical exam.

Upload supported file (Max 15MB)

We will conduct a fitness regime and need assurance the student is physically fit. Please make sure exam form includes doctor's signature.

I certify the information contained herein is true, completed and correct to the best of my knowledge and belief.

BMOGS Scholarship Application

Name*

Email Address*

What High School did you attend?*

What year did you graduate?

Grade Point Average (GPA)

Please list any groups, clubs, sports or other extra-curricular school activities you participated in. *

Please list any non-school related associations or groups you are involved with.ext Long

Please list any volunteer experience you may have.

Please email the following items to bspringfield797@yahoo.com.

High School Transcript, including final grades

300-word essay about why you are pursuing college and your career goals.

BMOGS Membership Application

Name*

Address*

Message*

Email Address*

Educational Background*

Career/Occupation*

Hobbies and Personal Interests

Please tell us why you believe your membership in this organization will benefit the youth we serve.*

Please tell us how many hours you are willing to donate on any given weekend or weekday. Please include if your contribution would be in the form of time, skills, mechanics, administrative duties or committee involvement. *

A $50 non-refundable application fee is required. Please check this box to signify that you agree to pay the fee and to attest that the information provided is accurate. Thank you.*

Please check here.

BMOGS WEB DuBois Academy Job Application

Name*

Address*

Phone*

Email Address*

Position Desired *

Qualifications and Skills*

Professional/Personal References*

Other Considerations

Do you consent to a CORI background check? *

Yes

Covid Vaccination *

Please tell us how you learned about this work opportunity.

Please check the box below to attest that the information you have provided is true and accurate.*

Please check here.

Black Men of Greater Springfield

W.E.B DUBOIS ACADEMY
DUBOI

BMOGS Scholarship Application

BMOGS Membership Application

Black Men of Greater Springfield

Black Men of Greater Springfield

W.E.B DUBOIS ACADEMY DUBOI

BMOGS Scholarship Application

BMOGS Membership Application

Black Men of Greater Springfield

W.E.B DUBOIS ACADEMY
DUBOI