Youth Program Application

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth*

I am a

Rising Junior
Rising Senior

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

Please list up to 4 areas you would be interested in shadowing (examples: health care, engineering, accountant, PR Marketing, trades etc.)

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

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

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

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 Leadership Institute 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)

Youth Summer Institute Application

References

Extracurricular Activities at School

Awards/Honors

Essay Question

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.