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 March 22, 2024.

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.

Parent / Guardian Signature(Required)

Date(Required)

Parent / Guardian Information(Required)

Date(Required)