LEAD•INNOVATE•SERVE ADMISSIONS | BLACK GIRLS ROCK! Inc. | P.O. BOX 380186 | BROOKLYN, NY 11238
BLACK GIRLS ROCK! PRESENTS
THE 2015 BLACK GIRLS LEAD CONFERENCE APPLICATION
THE PRIORITY DEADLINE FOR SUBMISSIONS MADE ONLINE IS MAY 22, 2015 BEFORE 11:59PM
GROUND MAIL MUST BE POSTMARKED BY MAY 22, 2015
ROLLING APPLICATIONS WILL BE ACCEPTED UNTIL MAY 31, 2015
[FORMS E-MAILED OR MAILED W/ A POSTMARK AFTER THE FINAL DEADLINE WILL NOT BE REVIEWED]
APPLICATION FEE: $25.00 VIA PAY PAL, CHECK, OR MONEY ORDER
ABOUT BLACK GIRLS LEAD
BLACK GIRLS LEAD (BGL) is an international leadership conference for young
women of color. The mission of the program is to offer girls tools and resources
to become dynamic leaders, innovators, and public servants of the future. The
priority deadline is Friday May 22, 2015. Rolling applications will be
accepted until May 31, 2015.
GENERAL INFORMATION
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BLACK GIRLS LEAD is a four-day leadership conference for girls, which
will take place from Thursday July 30, 2015 - Sunday August 2, 2015in
New York, NY at Barnard College, Columbia University.
Conference applications are due May 15, 2015 by 11:59PM. Only
completed applications will be reviewed. The application fee is $25 USD.
Upon acceptance, participants must pay a conference activity fee of $400
USD (a cost equaling $100 USD per day).
BLACK GIRLS LEAD is a day conference. However we have limited
housing available for participants who are traveling from regions outside of
the New York Tri-state area (including our international participants).
International participants or attendees who are traveling from outside of
the New York metropolitan area, have the option to apply for campus
housing from July 29-August 2, 2015. The fee for campus housing is $600
USD.
Please note that need-based grants are available. Aide will be scaled and
provided according to the participant’s financial circumstances.
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PART I: APPLICANT BACKGROUND INFORMATION Name ____________________________________________________________________________ LAST FIRST (Legal) MIDDLE Home address _____________________________________________________________________ NUMBER / STREET (APARTMENT NUMBER, IF APPLICABLE) CITY / STATE / ZIP CODE OR PROVINCE / COUNTRY Applicant E-­‐mail address ___________________________________________________________ PLEASE PRINT CLEARLY. PROVIDE AN E-­‐MAIL ADDRESS YOU CHECK REGULARLY. Twitter Handle ________________ Applicant Cell-­‐phone (if applicable) Facebook URL ____________________________________ ________________________________________________ Date of birth (mo/da/year) ___________________________________________________________ Is English your first language  yes  no What is the primary language spoken at home? ___________________________________________ Do you speak any other languages fluently? __________________________________________________________________________________ *Please attach a copy of your most recent headshot to this part of the application. PART II: PARENT/GUARDIAN INFORMATION Parent/Guardian I Name: _____________________________________________________________ LAST FIRST (Legal) MIDDLE Parent/Guardian II Name: ____________________________________________________________ LAST FIRST (Legal) MIDDLE Parent/Guardian I: Home Telephone number ( )_________ Parent’s Cell number ( )___________ Work Telephone number ( )_________ E-­‐mail _________________________ Parent/Guardian II: Home Telephone number ( )_________ Parent’s Cell number (__) __________ Work Telephone number ( )_________ E-­‐mail _________________________ PART III: EMERGENCY CONTACT INFO The emergency contact should be someone other than the guardians listed above. Please provide the name, mailing address, e-­‐mail, and phone number here: _______________________________________________ _______________________________________________ _______________________________________________ PART IV: IMPORTANT HEALTH INFO Does your child have any health conditions we should be aware of (physical, psychological, etc.)? If yes, please describe here: _________________________________________________________________________________ PART V: ESTIMATED FAMILY INCOME: ____ under $20,000 ____ $21,000-­‐$40,000 ____ $41,000-­‐$60,000 ____ $61,000-$80,000
____ $81,000-$100,000
____ over $100,000
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PART VI: ACADEMIC & LEADERSHIP BACKGROUND Applicant’s School: _______________________________________________________________ NAME ADDRESS (Legal) TELEPHONE NUMBER Academic Standing: ______________________________________________________________ CUMULATIVE GPA LIST 3-­‐5 LEADERSHIP EXPERIENCE/S: ACTIVITY DESCRIPTION LIST 3-­‐5 OTHER EXTRA-­‐CURRICULAR ACTIVITIES: ACTIVITY DESCRIPTION LIST ANY HONORS OR AWARDS THAT YOU HAVE RECEIVED: NAME OF AWARD AND GRANTING ORGANIZATION DESCRIPTION PAGE 3
PART VII: SHORT ANSWERS
Please complete all required short answer questions. Your responses should be detailed
and well developed paragraphs.
A. Why are you interested in attending the BLACK GIRLS LEAD Conference and what do you
hope to gain from this experience?
B. What is your definition of a leader?
C. What is your strongest leadership attribute?
D. When you hear the phrase BLACK GIRLS ROCK! how does it make you feel? What does the
phrase mean to you?
E. If you were the president of the BLACK GIRLS ROCK! Literature & Film Club what would be
the top three books and movies that you would recommend and why?
F. If you were to create an “Empowerment Mixtape” what are the top five songs and artists that
would be included and why?
G. Share your life’s mantra. Tell us what phrase or saying inspires you to be your most dynamic
self. Why does this phrase empower you?
H. If given the opportunity to create a "mastermind alliance" or council of mentors including
prevalent Black leaders of the past and present, who would be on your council and why?
I. Technology is a powerful tool -- it can help us operate more efficiently at home, in school, or at
work. If you had the resources to develop new technology what would you build and how would it
benefit your community or the world?
J. What form of technology are you proficient in (coding, robotics, music production, film, etc.)?
PART VIII: PERSONAL ESSAY | Envision a Better World (500 words)
REQUIRED PERSONAL ESSAY | Envision a Better World (500 words) Shirley Chisholm, the first
black woman elected to Congress and the first Black woman to run for President said, “Service is
the rent we pay for the privilege of living on this earth.” How do you use your talent, intellect, and
resources to "pay your rent" and why is public service important to you?
PART IX: VIDEO BLOG | THIS IS WHY I ROCK!
THIS IS WHY I ROCK! Alice Walker said, "The most common way people give up their power is
by thinking they don't have any." In a 3 minute video blog tell us what makes you feel powerful,
brilliant, and dynamic. Tell us why you rock and how you endeavor to use your gifts to better your
local and global community.
X: HEADSHOT
Please submit a recent headshot.
XI: TRANSCRIPT/REPORT CARDS
Please submit a copy of your official transcript or report card with this application.
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XII: APPLICANT/PARTICIPANT AGREEMENT
I,________________________, attest that all the information submitted in this application is true. If accepted to participate in the BLACK GIRLS LEAD conference, I agree to attend the conference for the entire duration from July 30 – August 2, 2015. I also agree to oblige to the community rules, code of conduct, and safety guidelines. By signing below, I acknowledge that I have read, understand and agree to the terms outlined above:
APPLICANT SIGNATURE: ___________________________________ DATE: _________________________ XIII: PARENT AGREEMENT
Should my child be accepted, I, __________________________, the parent/guardian of______________________________, consent to her participation in the 2015 BLACK GIRLS LEAD Conference from July 30 – August 2, 2015 at Columbia University and Barnard College in New York City. I understand that, if accepted, my child must participate in the entire conference session. I agree to accurately dispel any health related issues affecting my child and will provide any applicable medication/s and provisions (including clear instructions) to the conference staff. I understand that my child may be dismissed if she fails to adhere to safety guidelines or rules of conduct.
By signing below, I acknowledge that I have read, understand and agree to the terms outlined above: APPLICANT SIGNATURE: ___________________________________ DATE: _________________________ XIV: PARENT ASSUMPTION OF RISK WAIVER
I, ___________________________, assume full responsibility for any risks, loss, or personal injury that may be sustained by me/my child, or any loss or damage to property owned by me/my child, during the time she is participating in, or traveling to or from the the BLACK GIRLS LEAD conference. I release and agree to indemnify and hold harmless BLACK GIRLS ROCK! INC. and BLACK GIRLS LEAD, its staff, employees and agents from any and all claims, actions, suits, procedures, costs, expenses, damages and liabilities, including attorney’s fees brought as a result of my child’s involvement in the BLACK GIRLS LEAD conference, and to reimburse them for any such expenses incurred. By signing below, I acknowledge that I have read, understand and agree to the terms outlined above: PARENT SIGNATURE: ___________________________________ DATE: ___________________________ XV: MEDICAL EMERGENCY TREATMENT
I authorize BLACK GIRLS ROCK! INC. and BLACK GIRLS LEAD confference staff to seek medical treatment for my child in the event of accident or illness. I understand that I should obtain health insurance coverage for my child prior to participating in the BLACK GIRLS LEAD conference. I further understand that I will be responsible for my child’s medical expenses. By signing below, I acknowledge that I have read, understand and agree to the terms outlined above: PARENT SIGNATURE: ___________________________________ DATE: ___________________________ ALL INFORMATION, REPORTS, AND RECOMMENDATIONS SUBMITTED TO BLACK GIRLS ROCK! Inc. BY OR FOR THE APPLICANT ARE CONFIDENTIAL. PAGE 5