SECTION 1: GENERAL INFORMATION & GUIDELINES · PDF fileSECTION 1: GENERAL INFORMATION & GUIDELINES Before completing your application, please review the general information and

5/26/2017 BLACK GIRLS LEAD | 2017 APPLICATION

https://docs.google.com/forms/d/1NtpaYFdjYr7YXuEhIsO2FExQMID38Z0Ttdu5y6I27gw/edit 2/18

SECTION 1: GENERAL INFORMATION & GUIDELINES

Before completing your application, please review the general information and guidelines below.

ABOUT BLACK GIRLS LEAD



BLACK GIRLS LEAD (BGL) is a fourday international leadership conference for young women of color. The mission of the program is to offer girls ages 1317 tools and resources to become dynamic leaders, innovators, and public servants.

DATES + LOCATION

The 2017 BLACK GIRLS LEAD Conference is a fourday nonresidential program to be held at the prestigious Ivy League campus of Barnard College at Columbia University in New York City from July 31August 3, 2017.

BACKGROUND INFO

The BLACK GIRLS LEAD Conference is designed to affirm Black girls' brilliance, to cultivate their leadership skills and to create a safe space for fellowship and sisterhood to flourish. Attendees will experience culturally relevant workshops, panel discussions, guest lectures and empowerment circles led by worldclass educators, artists, business moguls, research scientists, entertainers and other influencers.

FEE

The program participant fee for the fourday nonresidential conference is $300 (regular price $1,500). Through the generous support of the Nathan Cummings Foundation, Beverly Bond and other donors, 80%



of the fee ($1,200) has been underwritten resulting in the reduced program participant fee of $300.

ELIGIBILITY

Eligible applicants are girls: 1317 years old (12th graders/2017 graduating seniors are not eligible to apply) in good academic standing who exhibit strong leadership potential and interest in our learning modules who are interested in the African Diaspora and its arts, histories, and cultures who are concerned about issues impacting Black women and girls

APPLICATION OVERVIEW

The application includes sections for: Applicant background information, Parental/Guardian background information, applicant leadership background, short answer questions, essay question, video blog and miscellaneous documents. Please note that applications are due Wednesday June 7, 2017 by 11:59PM and only completed applications will be reviewed. Short answer questions should be thoughtful, descriptive and comprehensive (approximately threefive sentences long), essays should be clear and concise (approximately 500 words), and all other assets must be emailed to [email protected] by the aforementioned deadline. Please pay attention to questions that are designated for new applicants (who have not participated in BGR! programming) versus returning participants. ** All answers must be submitted via this google form, however, if you'd like to access a pdf copy of the application so that you can prepare your answers in advance please visit our website: www.blackgirlsrock.org to download the pdf version. **

APPLICANT BACKGROUND INFOPlease provide the mandatory background information.

2. Applicant's Name (Last, First) *

3. Applicant's Full Home Address (Enter Full

Address: Street, City, State, Zip) *



4. Applicant's Primary EMail *

5. Applicant's Social Media: Twitter + Instagram +

Snapchat + Facebook URL *

6. Applicant's Date of Birth (Month/Day/Year) *

7. Headshot + Bio: Please enter a google doc link to a document including your head shot and

brief bio (make sure the bio is no longer than threefive sentences and include your full name,

hometown, favorite hobby and why you rock). *

8. Is English your first language? Yes/No. *Mark only one oval.

Yes

No

9. What is the primary language spoken at home?

*

10. Do you speak any other languages fluently? Ifso, list the languages here: *



11. IMPORTANT APPLICANT HEALTH INFO: Does the applicant have any health conditions weshould be aware of (physical, psychological, etc.)? If yes, please describe here the conditionhere and list any medications that we should know about. Please note that acceptedparticipants must have doctor's permission to selfadminister any medication. Our staff will notbe responsible for storing or administering medication. *

PARENT/GUARDIAN BACKGROUND INFOPlease enter information for your parent/guardian and emergency contact.

12. Parent/Guardian I Full Name: (Last, First) *

13. Parent/Guardian I: Email *

14. Parent/Guardian I Cell Phone Number: *

15. Parent/Guardian I Work Phone Number: *

16. Parent/Guardian I Home Phone Number: *

17. Parent/Guardian II Full Name: (Last, First)



18. Parent/Guardian II: Email

19. Parent/Guardian II Cell Phone Number:

20. Parent/Guardian II Work Phone Number:

21. Parent/Guardian II Home Phone Number:

22. The emergency contact should be someone other than the guardian/s listed above. Pleaseprovide the name, mailing address, email, and phone number here: *

23. ESTIMATED FAMILY INCOME *Mark only one oval.

Under $20,000

$21,000$40,000

$41,000$60,000

$61,000$80,000

$81,000$100,000

over $100,000

ACADEMIC & LEADERSHIP BACKGROUNDPlease provide the requested the information below.



24. Academic Standing/GPA *

25. Applicant's School Name + Full Address (Name,Street, City, State/Providence, Country, ZipCode) *

26. Applicant's School Phone Number: *

27. Do we have permission to contact your school advisor or guidance counselor regarding anyacademic questions? *Mark only one oval.

Yes

No

28. If yes, please provide your school advisor or guidance counselor's contact information below(name, phone number and email):

29. List and describe two (2) of your strongest leadership experiences here: *



30. List at least two (2) additional extracurricular activities here and describe why you enjoy them: *

31. Please have a teacher, school guidance counselor or mentor provide a recommendation letter

on your behalf. Recommendation letters must be sent by the recommender via email to

[email protected]. You may also mail the original sealed copy to P.O. BOX

380186 Brooklyn, NY 11238. All recommendation letters must be written on official letterhead

and include the contact information of the recommender. Please confirm that you've read and

understand this information. *

Mark only one oval.

Yes. I understand.

No. I will contact you at [email protected] to ask clarifying questions.

32. Please submit a copy of your official transcript or report card via email at:

[email protected]. Please confirm that you've read and understand this

directive. *

Mark only one oval.

Yes. I understand.

No. I will contact you at [email protected] to ask any clarifying questions.

APPLICATION QUESTIONS, ESSAY, VLOGAll applicants must answer each question in this section.



33. Have you participated in BLACK GIRLS LEAD before? Select yes or no. *Mark only one oval.

Yes

No

34. BLACK GIRLS ROCK!: When you hear thephrase BLACK GIRLS ROCK! how does it makeyou feel? What does the phrase mean to youand how does it empower you? *



35. BLACK GIRLS LEAD: Why are you interested in attending the 2017 BLACK GIRLS LEADConference and what do you hope to gain from this experience? *

36. LEAD(HER)SHIP: What are your strongest leadership attributes and why? *

37. SHEROES: Who are three Black women (from the past/present) who inspire you and what aretheir qualities or contributions to the world that motivate you to be your best self? *



38. BE THE CHANGE: In a socialpolitical climate such as this there is an urgent need for us to bethe change that we want to see. Please identify your deepest social concern and list at least oneperson, organization or cause that you believe is doing a good job at standing up and forgingchange. *

39. PAY IT FORWARD BLACK GIRLS SERVE: Shirley Chisholm said, “Service is the rent we pay forthe privilege of living on this earth.” Briefly describe how you make a difference, serve or pay itforward in your respective community. *

40. MUSIC MATTERS: If you were booked to DJ the Women's March on Washington what are fivemusthave songs (include artists as well) that would be included? Why do these songs inspire,motivate or move you? *



41. INNOVATION MATTERS: You were granted funding to invent a technology to solve one personalor social problem. Describe the innovation, how it works and what problem it would address. *

42. GIRLS ROCK! TECH: Science, Technology, Engineering, and Math are becoming increasinglyimportant in the modern workplace, yet the gender and race gaps in STEM continue to persist.How do you think educators and program planners can make STEM more accessible to thelearning needs of girls of color? *

43. What form/s of technology are you already proficient in? Check all that apply. *Check all that apply.

Coding

Robotics

Music Production

Film/Media Technology

Software or application design

Engineering



44. Describe the level of proficiency you have in the areas of technology that you've listed above.

45. What form/s of technology are you interested in learning more about? Check all that apply. *Check all that apply.

Coding

Robotics

Music Production

Film/Media Technology

Software or application design

Engineering

46. ESSAY: You've been asked to testify before Congressional Black Caucus on Women & Girlsabout issues impacting Black women and girls locally and globally. In a 500 word persuasiveessay, please highlight an issue that you would like to address and provide three potentialsolutions that would help eradicate or raise awareness about this problem. *



47. VIDEO BLOG (VLOG) | THIS IS WHY I ROCK: In a 3minute video blog tell us WHY YOU ROCK!Who are you? What makes you awesome, unique and powerful? What do you stand for? Whatissues in todays society are most concerning to you? How do you use your voice to raiseawareness or enact change? Please enter a vimeo link + password here so that we ma accessyour vlog. *

PAST PARTICIPANTS ONLYIf you are a past participant, please answer the questions below then proceed to the next section. If you are a new applicant, please skip these questions and proceed to the next section.

BLACK GIRLS ROCK! Founder, Beverly Bond, with two BGR!

Alums



48. IMPACT: To what extent has the BLACK GIRLS LEAD conference impacted your life? Describehow you have benefitted from attending the program.



49. TOP 3 MOMENTS: Please reflect on your previous experience at BLACK GIRLS LEAD andidentify three different speakers, panels, and/or workshops that resonated with you the most.

APPLICANT + PARENTAL AGREEMENTSPlease read and sign with your esignature.

50. APPLICANT/PARTICIPANT AGREEMENT: Iattest that all the information submitted in this

application is true. If accepted to participate in

the 2017 BLACK GIRLS LEAD conference, I

agree to attend the conference for the entire

duration of the program. 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: *

51. APPLICANT AGREEMENT TIME STAMP * Example: 8:30 AM



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52. PARENTAL AGREEMENT: Should my child beaccepted, I, the parent/guardian, consent to herparticipation in the 2017 BLACK GIRLS LEADConference in New York City. I understand that,if accepted, my child must participate in theentire conference session. I agree to accuratelydispel any health related issues affecting mychild and will provide any applicablemedication/s and provisions (including clearinstructions) to the conference staff. Iunderstand that my child may be dismissed ifshe fails to adhere to safety guidelines or rulesof conduct. By signing below, I acknowledgethat I have read, understand and agree to theterms outlined above:

53. PARENTAL AGREEMENT TIME STAMP * Example: 8:30 AM

Send me a copy of my responses.

Documents

SECTION 1: GENERAL INFORMATION & GUIDELINES · PDF fileSECTION 1: GENERAL INFORMATION & GUIDELINES Before completing your application, please review the general information and