A parent or guardian should complete the application below to request that your teenager (13+) participate in the Young Influencer’s Program (YIP): Please enable JavaScript in your browser to complete this form.Name of Youth Applicant *FirstMiddleLastName of Parent or Guardian (1) *FirstLastName of Parent or Guardian (2)FirstLastPhone Number of Parent / Guardian *EmailEmailConfirm EmailCurrent State of Residence *ArkansasMississippiMissouriOklahomaTennesseeTexasCurrent City *Type your current cityZIP Code *5 digit ZIP Code to your home addressHow many children are in your household? *NumberEmergency Contact Name & Phone NumberHow does the Youth Applicant want to participate? *Write ArticlesInterview Leaders on VideoRecord Video InterviewsEdit VideoTake PhotographsResearch & WritingGraphicsSocial Media MarketingWhat type of job would you like? (No job is guaranteed)What types of questions would the Youth Applicant like to ask community leaders?Have you done any of the following on preentry.org? *Read ArticlesWatched VideosSearched for ResourcesSearched for AttorneysTaken a CourseNone of TheseIs the Youth Applicant currently enrolled in school? *YesNoCurrent School or Educational SettingSelect the highest grade level completed by the Youth Applicant, or select the present grade level: *Fifth Grade or BelowSixth to Eighth GradeNinth to Twelfth GradeHigh School GraduateSome CollegeSelect the Youth Applicant's current age: *13141516171819202122List any youth program involvement:Identify days when the Youth Applicant will be most available to participate in training or interviews: *Mondays after 4:00 p.m.Tuesdays after 4:00 p.m.Wednesdays after 4:00 p.m.Thursdays after 4:00 p.m.Fridays after 4:00 p.m.Saturday MorningsSaturday AfternoonsOther TimesDo you have any more comments or questions about this program?Will the parent or guardian sign a media release for the youth applicant? *YesNoI'm not sureI grant permission to PreEntry.Org and its agents the irrevocable and unrestricted right to reproduce the photographs and/or video taken of the youth applicant for the purpose of publication, promotion, illustration, advertising, or trade, in any manner or in any medium. I hereby release PreEntry.Org and its legal representatives for all claims and liability relating to said images or video. Furthermore, I grant permission to use statements that were given during an interview or guest lecture, with or without my name, for the purpose of publication, advertising and publicity without restriction. I waive my right to any compensation unless compensation is otherwise agreed to in writing.I, the parent or guardian of the youth applicant, agrees to the foregoing permissions and releases.I, the youth applicant, agrees to the foregoing permissions and releases.I do not agree to the foregoing permissions and releases.NameSubmit YIP Application
