2023-2024 Youth Leadership Application

Student's name:

First Name *

Last Name *

Name as you'd like it to appear on your name tag: *

Address

Address Line 1 *

Address Line 2

City *

Zip/Postal Code *

Home Phone *

Cell Phone *

Cell Phone Carrier (AT&T, Verizon, etc.) *

Student's email *

Date of birth *

Format: M/d/yyyy

School Attending in September 2023 *

Grade in September 2023 *

Preferred method of contact *

Cell Phone Text Home Phone Email

Please check one.

Preferred Pronouns

He She They Other (please specify) Prefer not to disclose

Please check one.

Preferred email address for Youth Leadership Program communication (please choose an email address that you check frequently). *

The following questions are used only for statistical purposes:

Race and Ethnic Identification

Hispanic/Latino White African American Asian American Indian Native Hawaiian/Other Pacific Islander

THIS SECTION MUST BE COMPLETED BY A PARENT OR GUARDIAN

Parent(s)/Guardian(s) Name

First Name *

Last Name *

Parent or Guardian Cell Phone: *

Cell Phone Carrier (AT&T, Verizon, etc. *

Parent or Guardian Home Phone *

Parent or Guardian email *

Preferred method of contact *

Cell Phone Text Home Phone Email

Please check one.

Emergency Contact for Your Child

Name: *

Phone Number *

Doctor Name

Doctor phone number: *

Any special dietary needs, including allergies:

Medications:

Fee Structure *

Total Family Income = $0-$50,000 | Program Fee: $100/Scholarships available* Total Family Income = $51,000-$100,000 | Program Fee: $200/Scholarships available* Total Family Income = $101,000-$150,000 | Program Fee: $300 Total Family Income = $151,000+ | Program Fee: $350

Please check the appropriate category. *Scholarships are granted to students with little to no family income on a first come/first served basis until funds are depleted.

STUDENT - Name/Photograph Release

Press organization and the Dutchess County Regional Chamber of Commerce/The Chamber Foundation, and our partnering presenters and hosts, may write stories on the Leadership Connections Program and/or activities and benefit the youth by displaying their achievements. Please indicate whether you will allow your name and/or photograph released to the press. *

My name and photograph may be released to the press My name and photograph may NOT be released to the press

I agree to be an active participant in the Youth Leadership Program (YLP) throughout the school year. I will attend the monthly YLP meetings and actively participate in project work. I will respect the presenters and the other students in the program. If I miss 2 or more YLP sessions, I will make them up by participating in 5 hours of community service time for every missed meeting. *

Please type your name - this acts as your digital signature.

Date of signature *

Format: M/d/yyyy

PARENT OR GUARDIAN

My child had my permission to participate in the Youth Leadership Program. I agree to arrange for transportation for my child to and from YLP sessions. I understand that my child should be at the YLP sessions 10 minutes prior to start time. *

Please type your name - this acts as your digital signature.

Date of signature *

Format: M/d/yyyy