BRILLA Application

If you received a personal invitation to apply to the BRILLA Program, use the form below.

This form must be signed by the parent or guardian of the student. The due date for submission of applications is April 8, 2023.

Student Information

Name(Required)

First Last

Home Address(Required)

Street Address Address Line 2 City State ZIP Code

Personal Cell Phone

Home Phone

Email(Required)

Age(Required)

Grade(Required)

Parent / Guardian Information

Name(Required)

First Last

Relationship to Student(Required)

Phone(Required)

Email(Required)

Emergency Contact Information

Name(Required)

First Last

Phone(Required)

Email(Required)

Parental Permissions

The following fields MUST be filled out by a parent or guardian. By checking the permission boxes and signing your name, you agree to the terms indicated.

Permission for Attendance(Required)

By checking this box I agree to the below:

I give permission for this individual, named above, to attend the 2022 BRILLA summer leadership intensive program of the Hispanic Alliance of Southeastern Connecticut from 10:00 am to 3:00 pm over July 11 to July 15, 2022. Attendance for the entire week is required to obtain the 2022 BRILLA diploma of participation and be considered for a BRILLA college scholarship in senior year.

Parent / Guardian Signature(Required)

Date(Required)

Permission for Media(Required)

By checking this box I agree to the below:

I give permission for the video and audio recording of the 2022 BRILLA sessions in which this individual, named above, will participate. The video and audio recordings will be posted on the Hispanic Alliance of Southeastern Connecticut webpage.

Parent / Guardian Information(Required)

Date(Required)