e2 Fellowship Application

Applicant Information
School District*
School Name*
Name*
First Last
Date of Birth
Month
Day
Year
Address*
Street Address City State / Province / Region ZIP / Postal Code
Phone
Email*
Participant Level*
Local Newspaper:*
Special Dietary Restrictions
T-Shirt Size
Parent/Guardian Name
First Last
Parent/Guardian Email
Parent/Guardian Mobile Phone
Applicant Essay
Please explain what the phrase "education empowers" means to you.*
Participant Agreement
2024 - 2025 e2 Fellowship Dates
October 1 | November 19 | January 21 | April 1
I agree*
I agree to participate in all e2 Fellowship sessions listed above.
Photo/Media Ownership Release Agreement
I understand that the photographic image(s), video(s), and/or audio recording(s), in which I am a participant/subject, is(are) being produced and owned by Mosaic Life Care Foundation. I hereby acknowledge that my participation may be edited and used in whole or in part as desired in any way by the Foundation including, but not limited to, being reproduced, duplicated, and used for non-theatrical audiovisual informational, public relations, fund development, and general education purposes. I also consent to the use of my likeness and voice for all purposes listed above in connection with the images and audiovisuals through traditional print, radio, television and/or online media platforms for an indefinite period of time. I understand that my signature indicates that I have read, understand and approve of this photo release agreement.
I am 18 years of age or older, and I am competent to contract in my own name. I have read this authorization before agreeing below, and I fully understand its contents, meaning and impact. I agree to this media ownership release:
- Yes
- No
CONSENT OF PARENT OR GUARDIAN: For use if the person participating is a minor or otherwise not competent.
I agree to this media ownership release.
I hereby certify that I am the parent/guardian, and do hereby give my consent without reservation to the foregoing on behalf of this person. I agree to this media ownership release:
Registration Payment
e2 Fellowship will be offered free of charge through 2025 for school districts in the Foundation's 31 county service region in northwest Missouri and adjacent counties in Kansas, Nebraska and Iowa. The 4 days of program facilitation, all materials, and lunches are provided. Transportation or lodging costs are not included. Applicants are accepted on a first-come, first-served basis for up to 20 teams.

e2 Fellowship Application

Applicant Information

Applicant Essay

Participant Agreement

2024 - 2025 e2 Fellowship Dates

Photo/Media Ownership Release Agreement

Registration Payment

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