LACE Membership

Address

Race/ethnicity (mark all that apply)

White Black Latina Hispanic Asian African American
Name of School

Address

Grade entering Fall 2017
Parent/Guardian Information
Name

First Name Last Name
Phone Number

Area Code Phone Number
Email
example@example.com
Place of Employment
Job Title
Directions: In 250-300 words answer the following question in the box provided below.
If you could change one thing about your community, what would it be and why?
What does empowerment mean to you? Do you have someone who empowers you in your life? Who? Why?
Shirt Size
Enter the message as it's shown *
Should be Empty: