YCLE Application Application for Youth Civic Leadership Experience Name (First, Last) First Name * Last Name * Age * What is your age? Home Address What is your address (street, city, zip)? Address Line 1 * Address Line 2 City * State * Select option... Alabama Alaska Arizona Arkansas California Colorado Connecticut DC Delaware 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 DC Zip/Postal Code * Email Address What is your email? Cell Phone Number * What is your cell phone number? Shirt Size * XS S M L XL XXL Other What is your t-shirt size for unisex cut shirts? School * Atlantic Warner Father Lopez Burns Sci-Tech NSB Other What is your school name? Parent/Guardian Name * What is your parent/guardian first and last name? Parent/Guardian Contact * What is your parent/guardian cell phone number? GPA * What is your cumulative GPA? Scholarship Request * Yes No Are you requesting a scholarship to cover the cost of this program? Free/Reduced Lunch * Yes No Are you currently on free/reduced lunch? Special Requirements Please list any special requirements: dietary, physical, or other: Section 2 Community Involvement Interests/Hobbies * Please list any interests or hobbies that you have. Employment * Please list any employment roles that you've held: School Activities * Please list any high school activities that you're involved in: Community Activities * Please list any community activities that you're involved in (i.e. volunteering, church, etc.): Section 3 Short Answer Questions What are your reasons for applying for the Youth Civic Leadership Experience? What unique contribution will you bring to the group? What would you like to gain from this program? * What are the most important qualities of an effective leader? What does leadership mean to you? Describe a time you have had the opportunity to test your leadership abilities. * Name a person who has had a tremendous impact on you. Describe how and why this person impacted your life. * What do you see as a significant challenge facing your community? Please share your ideas for addressing this challenge. * Section 4 Commitment and Consent Applicant - Type your name below as an agreement to this statement: I hereby certify that all information contained in this document is true and accurate to the best of my knowledge. I hereby give consent to Youth Civic Leadership Experience to access and release all the above information, including my photograph, as necessary to conduct Youth Civic Leadership Experience business and promotions. I understand and agree that if I am selected to participate in this program, I will be required to attend every session in its entirety and to participate fully in all activities. * Applicant - By typing your name above, you are signing that you agree to the above statement. Parent/Legal Guardian: Type your name below as an agreement to this statement: I hereby grant permission for my guardian to apply for Youth Civic Leadership Experience; and if selected, to participate in the program. I hereby give consent for the student’s photograph to be taken during the program and used, as necessary, for Youth Civic Leadership Experience business and promotions. I understand and agree that if my child is selected to participate in this program, he/she will be required to attend every session in its entirety. I understand that the student must arrange his/her own transportation to and from the Port Orange South Daytona Chamber of Commerce Riverside Pavilion daily (point to point transportation during the day will be provided on a bus). I understand there is a $75 fee associated with this program, payable upon selection, unless student is granted a need-based scholarship. * Parent/Legal Guardian: By typing your name above, you are signing that you agree to the above statement. Please provide the name and email address of the teacher/mentor/coach who will complete your letter of recommendation. We will send them a separate form to complete. * Be sure to notify your teacher/mentor/coach that they will receive an email with instructions. Second Letter of Recommendation: Please provide the name and email address of the teacher/mentor/coach who will complete your letter of recommendation. We will send them a separate form to complete. * Be sure to notify your teacher/mentor/coach that they will receive an email with instructions.
