Leaders in the Paint

Name

First

Last

Full Name of Youth Participant

Age

Grade Level (Fall 2025)

School Attending (if applicable)

Gender Identity (Optional)

Parent/Guardian Full Name

First

Last

Parent/Guardian Email

Phone Number

Relationship to Participant

What City and Neighborhood Do You Live In?

Address

Session locations will be held at Alameda High School, but may change or rotate based on availability. Will your child be able to regularly attend these sessions?

Yes, we are able to attend regularly
No, we may have scheduling conflicts
No, we may have conflicts with transportation
I’m not sure yet – please follow up with me

How did you hear about this program?

What interests you (or your child) about Leaders in the Paint?

Does your child currently participate in organized sports or school activities?

Yes
No

If yes, please describe

What areas would you like your child to grow in through this program?

(Check all that apply)

Emergency Contact (Other than Parent/Guardian)

First

Last

Emergency Contact Phone Number

Does the participant have any allergies or medical conditions we should know about?

Yes
No

If yes, please explain

Consent & Waiver – By checking below, I give permission for my child to participate in Bickerstaff Inc.’s Leaders in the Paint program. I understand there may be physical activity and grant permission for emergency care if necessary.

I Agree

I give permission for my child’s photo/video to be used in program promotions and media.

Yes
No

participant give

Digital Signature (Type Full Name)

Date

LEADERS IN THE PAINT

APPLY TODAY