Enrollment Application

Thank you for your interest and support of Little Black Pearl. Please complete the following form to apply for one of the youth programs offered by Little Black Pearl. A Program Coordinator will follow up within 48 hours of receiving your application.

Please complete the form below

I certify that the applicant is a resident of the City of Chicago and will be between the ages of 14-19 at the beginning of the current school year. All other submissions will be void.

Student Information

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email Address

Date of Birth

MM

DD

YYYY

Home Phone

(###)

###

####

Cell Phone

(###)

###

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Student ID#

CHA ID# (If Applicable)

Name of School

Program of Interest

Select

Parent/Guardian Information

Parent/Guardian Name

First Name

Last Name

Parent/Guardian Phone

(###)

###

####

Parent/Guardian Work Phone

(###)

###

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Enrollment Application

Please complete the form below

1060 EAST 47TH STREET • CHICAGO, ILLINOIS 60653

773.690.5500