Confidential Application Form Objective

Time Commitment and Behavioral Expectations:

• 
  If selected, you commit to attending the Orientation, Retreat, four (4) Program Sessions and Graduation. Please note: Your application is a commitment to attend the Volunteerism Session on MLK Holiday.
  
• 
  Being on time for all events and actively participating in all activities is mandatory for maximum benefit from the Youth Leadership Athens program.
  
• 
  Attentive, respectful, and appropriate behavior is expected at all venues.
  

Applicant’s Signature _______________________________________________________

Parent’s Signature __________________________________________________________
DEADLINE: Noon, FRIDAY, September 30, 2016

Completed applications must be returned to your school’s counseling center or mailed to

Susan Mull, 330 Skyline Parkway, Athens, GA 30606
(Please print, type or recreate on computer using same format.)

1. 
   PERSONAL INFORMATION:
   

Name _______________________________________________________________________________________________

(Last) (First) (Name preferred)

Home Address ________________________________________________________________________________________

(Street and Number)

City ________________________________ Zip Code _________ County of Residence_________________

* Priority for participation is given to residents

of Clarke County

School__________________________________ ______ Grade level________________________________________

Phone_________________________________________ E-Mail_____________________________________________

Date of Birth ________________________ Gender ___________ Ethnic Background (optional) _____________________

Name of Parent or Guardian ____________________________________________

Parent/Guardian E-Mail ___________________________ Parent/Guardian phone_________________________________
___________________________ _________________________________
Are there any medical problems or allergies we should be aware of?

EMPLOYMENT: (if applicable)
Employer Title Period of Service
If you are selected for Youth Leadership Athens, will your work hours be flexible to allow for full participation?

2. 
   ORGANIZATIONS AND ACTIVITIES:
   

Please list activities, organizations, or hobbies in which you have been involved (clubs, athletics, volunteer/community service, religious, scouting, after-school lessons, etc.) and the role you played in the activities.

Activity/Organization How long have you participated? Role played/Office held – if applicable


List any honors, awards or recognitions you have received:

If your participation in activities/organizations has been limited, please indicate the reasons.

 Time  Lack of interest  Transportation  Work  Financial Reasons  Family responsibilities  Other (describe)

III. THOUGHTS ON LEADERSHIP ESSAY:
Identify a situation that you have observed at school or in the community and describe

how leadership affected the decisions that were made.
** The essay must be typed and attached to the application.

IV. RECOMMENDATIONS:
Along with your application, please submit two (2) completed recommendation forms (see attached). These recommendations should be written by the following adults outside your family:

1. 
   One school official (teacher, counselor, club advisor, principal/headmaster, etc.) who knows you
   
2. 
   One adult in the community (minister, employer, volunteer supervisor, etc.) who knows you
   

NOTE: Each recommendation must be returned in a sealed envelope with the endorser’s signature across the outside flap.

IV. TUITION AND NEED-BASED FINANCIAL ASSISTANCE:
Tuition: $150.00

Tuition payment may be made in more than one installment. A deposit of $50.00 must be paid by Orientation

on November 13, 2016. The balance must be paid before or on December 11, 2016. (Retreat).
Need-based Financial Assistance Information:

Youth Leadership Athens is committed to providing financial assistance, not to exceed $100, to those students

who demonstrate a need. A student’s request for financial assistance will not affect acceptance into the

program. Information will be confidential and every effort will be made to provide assistance where it is

needed.

To be considered for financial assistance, please attach a statement of need/explanation.

The statement must be signed by a parent.

The requested tuition amount is _________.

Deadline for Applications: Noon, Friday, September 30, 2016
Return completed application (with two sealed and signed envelopes containing

recommendations) to the counseling center of your school or mail to

Susan Mull, 330 Skyline Parkway, Athens, GA 30606.

Thank you for being candid and specific as you complete this recommendation. Please place the form in an envelope, seal and sign your name across the flap. The sealed envelope should be returned to the student prior to the application deadline of noon, Friday, September 30, 2016.

Youth Leadership Athens 2016-2017

Reference Form - School

Student’s Name _______________________________________________________

In what capacity have you known student? __________________________________
Length of time _______________________

1. 
   T
   Disagree Agree Strongly Agree

   1 2 3 4 5

   
   his student would benefit from participation in this leadership program.
   

Comments:

2. 
   T
   Disagree Agree Strongly Agree

   1 2 3 4 5

   
   his student could make positive contributions to the leadership program as a group member.
   

Comments:

3. 
   T
   Disagree Agree Strongly Agree

   1 2 3 4 5

   
   his student has demonstrated leadership in the school and/or community and/or among
   

peers.

Comments:

Disagree Agree Strongly Agree

1 2 3 4 5

4. 
   This student has a potential for developing or strengthening leadership qualities.
   

Comments:
Are there any problems (medical, emotional, behavior) of which the selection committee should be aware?
NAME ___________________________________________ PHONE ________________________________________
E-MAIL ADDRESS_________________________________________________________________________________
Thank you for being candid and specific as you complete this recommendation. Please place the form in an envelope, seal and sign your name across the flap. The sealed envelope should be returned to the student prior to the application deadline of noon, Friday, September 30, 2016.
Youth Leadership Athens 2016-2017

Reference Form – Community

Student’s Name _______________________________________________________

In what capacity have you known student? __________________________________
Length of time_________________________

1. 
   T
   Disagree Agree Strongly Agree

   1 2 3 4 5

   
   his student would benefit from participation in this leadership program.
   

Comments:

2. 
   T
   Disagree Agree Strongly Agree

   1 2 3 4 5

   
   his student could make positive contributions to the leadership program as a group member.
   

Comments:

3. 
   T
   Disagree Agree Strongly Agree

   1 2 3 4 5

   
   his student has demonstrated leadership in the school and/or community and/or among
   

peers.

Comments:

Disagree Agree Strongly Agree

1 2 3 4 5

4. 
   This student has a potential for developing or strengthening leadership qualities.
   

Comments:
Are there any problems (medical, emotional, behavior) of which the selection committee should be aware?

NAME ___________________________________________ PHONE __________________________________________

E-MAIL ADDRESS___________________________________________________________________________________

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