BIKE-A-THON

APPLICATION

The De’Lindsey Mack Youth Empowerment Program is dedicated to empowering youth through education, mentorship, and opportunity. The program provides financial scholarships, student mentoring, and coaching for individuals pursuing higher education at colleges or trade schools.

The Break The Cycle Bike-a-Thon builds on this mission by rewarding positive behavior and encouraging personal growth. As part of this initiative, 25 deserving youth will be awarded brand-new bicycles as an incentive to stay on the right path, make positive choices, and continue striving toward their goals. All recipients must meet the following eligibility requirements:

Submit a completed online Bike-a-Thon application.
Upload a copy of a recent Progress Report, Report Card, or Weekly Report.

Personal Information

Student Full Name

Parent or Guardian Name

Student Phone Number

Parent or Guardian Phone Number

Student Birthday

Month

Day

Year

Multi-line address

Country/Region

Address

Address - line 2

City

Zip / Postal code

Education Information

School Name

Conduct Grade

Excellent

Satisfactory

Proof of Conduct Grade

(examples: Progress Report, Report Card, Weekly Report)

Personal Disclaimer

I hereby give permission to members of De’Lindsey Mack Youth Empowerment Program to access my academic and conduct records for the sole purpose of determining my eligibility. I understand that this waiver of my Family Rights and Privacy Act (The Buckley Amendment) rights to confidentiality applies to enrollment and transcript information, including my grade point average, as well as financial aid information. I also understand that this waiver will remain in effect so long as I remain enrolled at my University/College, or until such time as I revoke this waiver by informing the De’Lindsey Mack Youth Empowerment Program, whichever is sooner. I also attest that the foregoing application information is correct and true to the best of my knowledge.

Check below to indicate that you have read and agree with the acknowledgement above.

Yes, I agree to the above statement.

Yes

If I am a recipient of the DMYEP Break the Cycle Bike-a-Thon, I give permission to have my picture posted on the site as a recipient.

Yes, I agree.

No, I do not agree.

Parent or Guardian Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Signature grants permission to DMYEP for the screening of a minor.