Zone Membership Form

Please complete all requested information on this form and then click "Submit."


First Name:         Last Name:   

School: 

Another Course to College/Boston Community Leadership Academy

Boston International High School    

Boston Latin Academy    

Boston Latin School

Brighton High School   

Brook Farm/Media High School/Urban Science Academy (W. Roxbury)

Charlestown High School  

Community Academy of Science and Health

Dorchester Academy    

East Boston High School   

English High School

Excel High School (S. Boston)   

Fenway High School

Jeremiah E. Burke High School   

John D. O'Bryant High School

Madison Park High School   

New Mission High School

Snowden International School at Copley 

TechBoston Academy

School ID#: 

Date of Birth:       Gender:        Male Female  
                            (MM/DD/YYYY)

Email:                      Phone#:      

Grade: Freshman (9th)  Sophomore (10th)    Junior (11th)    Senior (12th)

Sport(s): Football   Soccer   Volleyball   Indoor Track  Outdoor Track

               Basketball Softball    Baseball  Cheerleading  Swimming 

                Cross Country

               Other:

Parent/Guardian Information:

First Name:       Last Name:

Mailing Address:  

Home Phone:     Cell Phone:

Parent's Email Address:

Emergency Contact Name:      

Emergency Contact Number:

This application is factual and complete to the best of my knowledge. I understand that participation is contingent upon reviewing the Zone Scholar-Athlete Handbook and a commitment to attend an orientation session. I give my consent for photographs, audiotapes, and video recordings of my son/daughter to be used by the Boston Scholar Athlete Program (BSA) for publicity purposes. The BSA has permission to access and review my student's grades, PSAT, SAT, MCAS scores, while enrolled in the Boston Public Schools and to contact medical authorities in the event of a medical emergency.

By signing below, it is understood that the BSA's policies & procedures will be adhered to. Failure to comply with The Zone Code of Conduct can lead to removal from the program.

Parent/Guardian Signature:    Today's Date:   
 
   By checking this box, I am hereby certifying that I am the parent/legal guardian of
        (first and last name of child)

        

  

Scholar-Athlete Signature:     Today's Date: