[Secure Form] EMPOWER 2021 (BROM)

Section 1 of 1 in this document

Are you over 18 years of age?

Yes

Student’s First Name

Student’s Last Name

Parent’s First Name

Parent’s Last Name

If nominating a student, please share your name and how you know them.

Phone Number

Student's Age

Name of School

City of School

Grade Level

How did you hear about our EMPOWER Human Kindness program?

Other

Please answer the following questions. You can submit your answers by typing below, uploading a video, or uploading a document (PDF preferred).

How do you EMPOWER Human Kindness in your school or community? (up to 750 words)

How would you like to EMPOWER Human Kindness in your school or community if selected as our EMPOWER HUMAN Kindness Ambassador? (up to 750 words)

Please upload your video or document (up to 50MB)

Click Here to Upload

Share a link to your video (YouTube, Vimeo, DropBox, Google Drive)

*Must be submitted by a parent if the student is under 18 years old at the time of submission.

Below are the updated Terms and Conditions for the Smile Again program. Please indicate that you have read and agree to the updated Terms and Conditions.

I have read and agree to the Terms and Conditions of the Smile Again program (listed below).

I agree

Click here to review the Official Terms & Conditions .

You are required to fully review the Official Terms & Conditions of the Smile Again Program prior to submitting your initial application.