Youth Program Application Name First Name * Last Name * Name You Prefer to be Called Preferred Pronoun he, him, his she, her, her they, them, their Birthdate * mm-dd-yyyy Ethnicity School Name * Grade in School * Rising 9th Grader Rising 10th Grader Rising 11th Grader Rising 12th Grader GPA * Out of (highest possible GPA) * Student Email * Home Address * City * State * - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code * Cell Phone Number * How did you hear about the Youth Program? * Select your program: * Rising 9th and 10th Grade Students: Monday, July 19th – Friday, July 23, 9:00 a.m.-12:00 p.m. Rising 11th and 12th Grade Students: Monday, July 19th – Friday, July 23, 1:00 p.m.- 4:00 p.m. Parent/Guardian Email * Parent/Guardian Address (if different) City Zip Code State - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Cell Phone Number * Relationship to student * Why are you interested in this program? What do you hope to gain from it? * 100 word limit Describe an individual whose leadership style or skills you admire. How have you been influenced by this person? * 100 word limit How do you spend your time outside of school studies? * 100 word limit What is the most important thing you would like to share about yourself? * 100 word limit Signed (applicant) * Parent/Guardian: I give my permission for my child to participate in the Leadership Arlington Youth Program. Upon notification of acceptance into the program, I understand that Leadership Center for Excellence will notify my child and me of my child's acceptance into the Youth Program within two weeks of receiving my child's completed application and youth program reference form. At which time I will pay Leadership Center for Excellence the agreed-upon tuition fee within two weeks of acceptance. I also understand that scholarships are available, and no student accepted into the program will be turned away for financial reasons. Signed (parent) *
