LearnServe International Incubator Student 2023-24 Application
Thank you for your interest in the LearnServe International Incubator Program. Please complete the following application to be considered for the Program. All required fields must be completed.
Once you have submitted your application, the LearnServe team will follow up regarding next steps in the application process, including an interview. Questions? Contact Latoya Felder at latoya@learn-serve.org
Demographic Information
I am a ... *
New Applicant
LearnServe Alum
First Name *
Last Name *
Your Email *
Cell Phone *
Street Address/ Compound *
City/ District *
State/ Province *
Zip Code
Ward/County/ Constituency *
Ward 1 Ward 2 Ward 3 Ward 4 Ward 5 Ward 6 Ward 7 Ward 8 Alexandria Arlington County Fairfax County Falls Church Montgomery County Prince George's County I don't know
Birth Year *
I am currently: *
A high school student
A college/university student
An employed youth
An unemployed youth
What school do you/did you attend? *
School Type *
Independent / Private School
Community School
Public School
Government School
Charter or Public-Charter School
Expected high school graduation year *
2019
2020
2021
2022
2023
2024
2025
2026
2027
Please specify the gender you most identify with at this time: *
Female/Girl/Woman
Male/Boy/Man
Nonbinary/Gender Queer/Gender Non-conforming
I prefer not to say
Other
Pronouns *
she/her/hers
he/him/his
they/them/theirs
ze/zir
I don't know yet
Please specify the racial or ethnic identity category you most identify with on the census (Please choose one): *
American - Indian or Alaska Native
Asian-American and/or Pacific-Islander
African-American and/or Black
Hispanic and/or Latino/a/x
White American
Zambian
I prefer not to say
I identify with multiple categories
Do you receive free or reduced price lunch from your school? (US Only) *
Yes
No
I don't know
Does not apply
Do you receive Medicaid (US) or NHIMA (Zambia) benefits? *
Yes
No
I don't know
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Parent/Guardian Information
Parent/Guardian 1 First Name *
Parent/Guardian 1 Last Name *
Parent/Guardian 1 Email *
Parent/Guardian 1 Cell Phone
Parent/Guardian 1 Home Phone *
Parent/Guardian 1 Work Phone
Parent/Guardian 1 Relationship *
Mother Father Step-mother Step-father Grandmother Grandfather Aunt Uncle Sister Brother Foster parent Guardian Significant Other Husband Wife Friend Other
Parent/Guardian 1 Same address as you? *
Yes No
Parent/Guardian 1 Address (if different from yours)
Parent/Guardian 2 First Name
Parent/Guardian 2 Last Name
Parent/Guardian 2 Email
Parent/Guardian 2 Cell Phone
Parent/Guardian 2 Home Phone
Parent/Guardian 2 Work Phone
Parent/Guardian 2 Relationship to you
Mother Father Step-mother Step-father Grandmother Grandfather Aunt Uncle Brother Sister Foster parent Guardian Significant Other Husband Wife Friend Other
Parent/Guardian 2 Same address as you?
Yes No
Parent/Guardian 2 Address (if different from yours)
Application Questions: 2-3 sentences will suffice for each question.
In no more than three sentences, describe your venture - including the problem you are solving, and the solution you propose. *
What stage in the venture process are you at (ex. Research, Design, Pilot, or Ready for Growth)? Describe what you have accomplished so far with your venture. *
How are you hoping to grow over this next year, personally and professionally? *
Additional Questions
How will you fit this commitment in with your other school and home responsibilities? Please note that this program will take place virtually every week on Saturdays, 10.00-12.00 noon EST // 16.00-18.00 CAT. You will also be participating in mentor sessions and 1-2 virtual retreats. *
I have access to the following: *
Internet
Zoom
Google Docs
All of the Above
Has your Parent or Guardian seen and approved of the program details? *
Yes, I have talked to my parent(s)/guardian(s) about applying to the LearnServe Incubator program.
No, I have not talked to my parent(s)/guardian(s) about applying to the LearnServe Incubator program.
Please fill out the captcha on the right.
