Apply
Use the form below to submit an application for a child to participate in the Youth Clubhouse Program. YOU ARE REQUIRED TO READ AND FOLLOW THE RULES & REGULATIONS OF THE PROGRAM THAT CAN BE FOUND HERE: Youth Clubhouse Program Rules. Completing this application means that you agree with our rules & regulations.
By completing the form, I agree for my child to participate in the “100” Youth Clubhouse Program located at 601 Union Street, LaGrange, Ga
We host two programs depeding on the grade that the student is in:
The “Youth Clubhouse Program” is for MIDDLE SCHOOL STUDENTS (Grade 6 -8) and is held on Monday - Friday from 4:00PM - 7:00 PM
The “Career Exploratory High School Program” is for HIGH SCHOOL STUDENTS (Grade 9 -10 only) and is held on Saturdays only from 11:00 AM - 2:00 PM
I also agree for my child to be transported to and from the program by the “100” transportation provider and to be photographed for project use.
I give permission for the 100 Black Men to collect my child’s report card and disciplinary reports during the school year.
Participants will participate in college tours, workforce development career & skills resources, transition guide information, college prepartation and financial aid information, create a career profile, and attend field trips outing/fun day events.
Participants selected for the clubhouse program will be administered a consumer satisfaction survey at the completion of the program.
Participants who attend the program on a regular basis (Saturday) and maintain good behavior may be eligible to attend field trip outings.
The 100 Black Men of West Georgia, Inc. agrees not to release any confidential records/information to any unauthorized person or agency without the written consent of the parent/guardian.
I have read and fully understand the above program description and operation. My signature indicates my consent for my child’s participation in the program.