Youth Leadership Clarksville Application Form

Personal Information
Name*
First Last
Preferred Name
Home Phone*
Cell Phone*
Email*
Sex*
Race*
Birth Date*
Grade in School*
- 10th
- 11th
School*
Home Address*
Street Address City State ZIP Code

School Experience
Other schools attended:*
List up to three special awards, honors or recognitions for academic, school or community related activities you have received from the 8th through your current grade.*
Main area of interest in studies:*
ORGANIZATIONS AND ACTIVITIES
Please list in order of importance to you up to five school, volunteer, religious, social, athletic or other activities or organizations in which you have participated during the last four years.*
Include: Organization/Activity, Grade in School, and Leadership Responsibility/Involvement
WORK EXPERIENCE
List any part-time job experience, paid or volunteer, and briefly tell what it involved.*
Do you currently have a part-time job?*
- Yes
- No
How many hours per week?*
Would your job interfere with your attendance at Youth Leadership Clarksville?*
- Yes
- No

General Information
1. What are the three greatest challenges facing Clarksville?*
2. What do you want to learn by being a part of Youth Leadership Clarksville?*
3. What are your leadership strengths?*
4. How do you prioritize the activities in which you are involved?*
ESSAY
Please respond to the following question in 250 words or less.
If you could change anything in your community, what would it be and how would you change it?*

REFERENCES
Please give one reference form to a teacher, counselor, advisor or the principal at your current school. Give the second one to any adult who knows you well, other than a parent or relative. For example, you may give it to another teacher or counselor at school, a scout leader, church youth leader, etc. If this is your first year at your current school, give this second reference to a teacher, principal or counselor at the school you attended last year.

Fill in the following information about both references so we can contact them if necessary.
First Reference
Name*
First Last
Phone*
Position/Title*
School/Firm/Organization*
Address*
Street Address City State ZIP Code
Second Reference
Name*
First Last
Phone*
Position/Title*
School/Firm/Organization*
Address*
Street Address City State ZIP Code
ATTENDANCE
100% attendance is expected of each participant and school attendance credit will be granted for each school day session attended.
If selected, do you make a commitment to attend each one of the program sessions from the Opening Orientation through Graduation?*
- Yes
- No
TUITION AND SCHOLARSHIPS
Tuition for the program is $100.00. A number of full and partial scholarships will be available on the basis of need. If you will require financial assistance to participate, check below. You may be contacted to supply additional information to determine eligibility. The need for financial assistance will not be considered in the selection process. Tuition is not refundable after class is selected and announced.
Do you require financial assistance to participate?
- Yes
Electronic Signature of Applicant*
Please type first name and last name.
Date*
Electronic Signature of Legal Guardian*
Please type first name and last name.
Date*
Electronic Signature of Principal or Guidance Counselor*
Please type first name and last name.
Date*
Consent / Verification*
I agree.
This verifies the school’s approval for the applicant to attend all sessions of Youth Leadership Clarksville. All applicants will be notified in writing of the selection committee’s decision. Finalists will be scheduled for a personal interview at a date to be announced.

Step 1 of 4

Personal Information

School Experience

ORGANIZATIONS AND ACTIVITIES

WORK EXPERIENCE

General Information

ESSAY

REFERENCES

First Reference

Second Reference

ATTENDANCE

TUITION AND SCHOLARSHIPS