Youth Leadership Clarksville Application Form THE DEADLINE FOR APPLYING IS APRIL 8 Step 1 of 4 25% Personal InformationName* First Last Preferred NameHome Phone*Cell Phone*Email* Sex*Race*Birth Date* Date Format: MM slash DD slash YYYY Grade in School*10th11thSchool*Home Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code School ExperienceOther 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 ACTIVITIESPlease 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/InvolvementWORK EXPERIENCEList any part-time job experience, paid or volunteer, and briefly tell what it involved.*Do you currently have a part-time job?*YesNoHow many hours per week?*Would your job interfere with your attendance at Youth Leadership Clarksville?*YesNo General Information1. 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?*ESSAYPlease 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?* REFERENCESPlease 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 ReferenceName* First Last Phone*Position/Title*School/Firm/Organization*Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Second ReferenceName* First Last Phone*Position/Title*School/Firm/Organization*Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code ATTENDANCE100% 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?*YesNoTUITION AND SCHOLARSHIPSTuition 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* Date Format: MM slash DD slash YYYY Electronic Signature of Legal Guardian*Please type first name and last name.Date* Date Format: MM slash DD slash YYYY Electronic Signature of Principal or Guidance Counselor*Please type first name and last name.Date* Date Format: MM slash DD slash YYYY 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.
