Embrace Your Best Self _TIE_ Program Application Form

Application

Welcome and thank you for your interest. This program is for youth and young adults ages 12-24, who identify as Black or African Descent living in King County, WA. Your application will be reviewed and confidentially processed. You will be notified by email with details pertaining to the next steps. Please make sure your contact information is correct.
Participant First Name*
Participant Middle Name*
Participant Last Name*
Email address*
example@example.com
Have you attended an information session?*

YesNo
Participant phone number*
Participant email*
example@example.com
Street address 1*
Street address 2
City*
Zip code*
Current School*
School status for fall 2024*

6th grade7th grade8th grade9th grade10th grade11th grade12 gradeEnrolled in GED programUndergraduate schoolGraduate schoolVocational trainingHigh school diploma (completed)Currently suspended or expelledNot completing high schoolOther
Employment status*

Employed - full-timeEmployed - part-timeEmployed - seasonalTrainingNot employed - looking for workNot employed - unable to workNot employed - not looking for workNot ApplicableOther
Date of birth*

MonthDayYear
Date
How do you identify

BlackAfrican AmericanAfricanOther
Gender*

FemaleMalePrefer not to sayNon-binaryTransgenderOther
Weekly 1 hour EYBS TIE cohort meetings are an internship requirement. Please let us know your availability during the week. Pick 3, one-hour time slots that work for you.

Monday 5pm - 6pmTuesday 5pm - 6pmWednesday 5pm - 6pmThursday 5pm - 6pmFriday 5pm - 6pmMonday 6pm - 7pmTuesday 6pm - 7pmWednesday 6pm - 7pmThursday 6pm - 7pmFriday 6pm - 7pmSaturday 9am - 10amSaturday 10am - 11amSunday 4pm - 5pmSunday 5pm - 6pm
Parent/ Guardian/ Caregiver Information

Please complete this section if you are under 18 years of age
Parent/ Guardian/ Caregiver full name
Parent/ Guardian/ Caregiver phone number
Parent/ Guardian/ Caregiver email
Media release- I understand that participant's image maybe captured on video/photography. I give permission and understand that there is no compensation provided for any appearance or statements recorded **

I consentI do not consent
Liability Waiver- I understand that there is a risk involved in physical activities and do not hold the institute or affiliates liable for any injuries or chronic condition that might develop as a result of participating. **

I consentI do not consent
Please tell us why you are interested in the Embrace Your Best Self Program and/or tell us what you hope to experience.*
Please tell us your ideas about what it means to be a successful adult.*
I certify to the best of my knowledge all my responses are accurate and truthful.
Please verify that you are human*
How did you hear about this?*
Name of person or organization
Mailing address 2

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Should be Empty:

Application

Parent/ Guardian/ Caregiver Information