D3 Application

First Name *

Last Name *

Gendar *

Male

Female

Age *

12-15

16-18

19-24

Birthday *

mm/dd/yyyy

Best phone number

Enter the best contact number to reach you cell or home.

Email Address

Not required but if you would like email updates enter your email here.

Address *

City *

State *

Zip *

Education and Employment (Check all of the boxes that apply to you.) *

Emergency Contact Name *

Emergency Contact Phone Number *

Emergency Contact Relationship *

Are you a parent? *

Yes

No

Program Interest (Choose which program(s) interest you.) *

Achievers - Literacy Program

Basketball Program

CORE - Entrepreneurship Program

College Tour

Choose one of the following based on your school lunch. *

Free Lunch

Reduced Lunch

Neither

Check yes or no if you agree to the following terms: You understand that D3 has the option to use all pictures, audio and video of you during D3 activities for social media, fundraising and marketing purposes. You assume all risks associated with D3 programs and release D3 from all liability for any loss, cost, expense, injury, illness, death or property damage resulting directly or indirectly from activities.

Yes

No

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D3 Community Outreach Inc.

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