Youth Program Application | Leadership Geauga

Name

First

Last

Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Date of Birth*

Email

Home Phone

Cell Phone

Cell Phone Carrier

Parent/Guardian*

Parent/Guardian Daytime Phone (in case of emergency)

High School

GPA*

Days absent during the last three school semesters*

Facebook Account Profile Name

Twitter Account Name

Shirt size*

Dietary Restrictions

How did you find out about the leadership Geauga County Youth Leadership program?*

At school
On the web
From a friend

References

School Reference Name:*

First

Last

Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Email

Phone

Community Reference name #1:*

First

Last

Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Email

Phone

Community Reference name #2:*

First

Last

Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Email

Phone

Work Experience

List all of the jobs you have held:

If you are currently working, list the name of the name of your employer (business) and how many hours you work each week.

Extracurricular Activities at School

Please list, in order of importance to you, up to four extracurricular activities in which you are involved at school.

Please include:

Activity/Organization - Your Leadership Position - Hours/Week - Years Involved

Extracurricular Activities in the Community

Please list, in order of importance to you, up to four extracurricular activities in which you are involved in the community.

Please include:

Activity/Organization - Your Leadership Position - Hours/Week - Years Involved

Awards/Honors

List major awards, honors or recognition you have received for academic, school, or community-related activities including the dates.

Essay Question

Please describe why you are applying to the Leadership Geauga Youth Program and what you hope to gain from the experience.*

Scholarship Application - Leadership Geauga County has a limited amount of financial aid available to individuals who could not participate in the program without subsidy. These funds are raised through corporate gifts, grants, and the annual fund raising activities.

Name

First

Last

school

Date

Reason for the request (a reason is required)

Amount requested

How will the remainder of the tuition be paid? (All participants must pay at least $100)