EmailMe Form - 2012-2013 Youth Leadership Program Application

Today's Date

MM / DD / YYYY

Name *

First Last

High School

Please note: Only participating 7 Rivers Region Schools

Home Address *

Street Address City State / Province / Region Postal / Zip Code Country / Region

Phone *

### - ### - ####

Email Address *

Emails will be sent out for reminders & updates if selected for the Youth Leadership Program.

Date of Birth *

Please answer each of the following questions in 50 words or less.

1.) What do you hope to learn through the Youth Leadership Program? *

2.) What qualities do you believe are necessary to be a leader & which of those qualities do you have? *

3.) Give an example of a leader who has influenced you & why. *

4.) List any school or outside activities that are important to you. Why are they important and what have you accomplished? *

I agree to the terms & conditions of the Youth Leadership Program. *

Yes

No

An important trait of being a leader is personal accountability. If you are selected for the Youth Leadership Program, you will be expected to be on time and attend all sessions through the program year. However, we realize that illness and other circumstances may cause an absence. Consecutive absences or non-excused absences will not be tolerated and may result in dismissal from the program.

Electronic Signature *

Please type your first & last name to confirm all information submitted is correct.

Don't delay! Application deadline is Friday, May 4.

Please contact Melisa Valencia with any questions at melisavalencia@centurylink.net or 608-784-4807.

Please answer each of the following questions in 50 words or less.

Don't delay! Application deadline is Friday, May 4. Please contact Melisa Valencia with any questions at melisavalencia@centurylink.net or 608-784-4807.

Don't delay! Application deadline is Friday, May 4.

Please contact Melisa Valencia with any questions at melisavalencia@centurylink.net or 608-784-4807.