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 May 7, 2021.

Student Information

Name(Required)
Home Address(Required)

Parent / Guardian Information

Name(Required)

Emergency Contact Information

Name(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)
Date(Required)
Permission for Media(Required)
Date(Required)