eXcel Application

July 16 - 19, 2019


INSTRUCTIONS:

1.    Please complete all sections of the application. You may include attachments if necessary and email to Alexis Epps, AEPPS@hrchamber.com

2.    Priority will be given to early applications; applicants will be accepted on a rolling basis.

3. The application, with signatures of the student and the parent/legal guardian, must be completed and received by June 21, 2019.


PERSONAL INFORMATION: *
PERSONAL INFORMATION:
Address *
Address
Home Phone *
Home Phone
Cell Phone *
Cell Phone
Gender *
Optional Racial/Ethnic
PARENT/GUARDIAN INFORMATION *
PARENT/GUARDIAN INFORMATION
Name *
Name
Address *
Address
Home *
Home
Daytime *
Daytime
Cell
Cell
Please list, up to five (5) school, volunteer, religious, social, athletic, or other activities or organizations in which you have participated.
Select one activity or organization listed above and briefly explain how your participation has benefited you.
List any awards, honors, or recognitions for academic, school, or community activities you may have received with year.
IV. GENERAL:
V. REFERENCES:
Two references are requested. Please complete the information below.
1. Principal or Headmaster *
1. Principal or Headmaster
Address *
Address
Phone *
Phone
2. Adult, other than a relative, who knows you well. *
2. Adult, other than a relative, who knows you well.
Address *
Address
Phone *
Phone
PARENT/GUARDIAN INFORMATION:
Cell *
Cell
Address *
Address
VI. ATTENDANCE + TUITION:
If selected, you agree to commit to attend the entire four day program. Full attendance and active participation is essential for a quality leadership experience. I understand and accept the attendance requirements for eXcel.
Limited financial aid is available. Do you require financial aid in order to attend?
Would you like to know more about a payment plan?