EmailMeForm
The 84 Movement SLT Application
If you’re looking for a way to protest the tobacco industry, create change, build leadership skills, and spread The 84 to other youth across the state, this group is for you. Doing all these things does require a commitment, though, so we want to make sure we pick the right candidates. We accept 20 youth each year to be a part of this program – one that will surely increase your confidence, make you more connected to your community, and potentially change your life for the better.
So what are you waiting for? Apply for The 84 Movement's Statewide Leadership Team below!
Please fill out the following information:
Name:
*
Chapter:
*
High School:
*
Your Phone Number:
*
Email:
*
Home Address:
*
City, State, and Zip
*
Birthday (eg 10/25/04)
*
Age:
*
Grade:
*
Pronouns you use:
Parent/Guardian Name:
*
Parent/Guardian Phone Number:
*
Parent/Guardian Email:
*
Emergency Contact Name:
(if same as above, write "same as above."
*
Emergency Contact Phone Number:
(if same as above, write "same as above."
*
Emergency Contact Name and Email:
(if same as above, write "same as above."
*
Describe your involvement with your 84 Chapter (how long you’ve been involved, activities you’ve participated in, relationship to other members and advisor).
*
Why are you passionate about tobacco prevention in your community?
*
How will you impact your community and the state by being a part of the Leadership Team?
*
What other after school activities are you actively engaged in?
*
Are you free on Sunday evening at 7pm for the weekly team meeting via phone/internet?
*
Yes
No
I don't know
Other (please specify)
What is your most preferred method of communication?
(From the list below, please number 1-5 with 1 being the most preferred way of communicating and 5 being the least preferred)
*
1 (Most Preferred)
2
3
4
5 (Least Preferred)
Phone call
Text
Email
Facebook Group/Message
Group Text
