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Student Leader APPLICATION

Rebirth Empowerment Academy Student Leader Application - April 2026

Full Name

Nickname or name you wish to be addressed

Date of Birth

Address

Phone

Email

SCHOOL

GRADE

PARENT-CARE PROVIDER NAMES

PARENT-CARE PROVIDER PHONE #'s

PARENT GUARDIAN EMAIL's

EMERGENCY FAMILY CONTACT (other than parent)

OTHER EMERGENCY CONTACT

PREFERRED EMERGENCY CONTACT

MEDICAL NEEDS/ALLERGIES

SPECIAL NEEDS/ACCOMODATIONS

How did you discover the REBIRTH EMPOWERMENT ACADEMY?

WHAT SKILLS-GIFTS-OR TALENTS ARE YOU GOING TO SHARE?

Application Sent!

Application Sent!

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253-380-4440

info@rebirthempowermentacademy.com

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1211 123rd Street CT E  
Tacoma, WA 98445

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