Request Headers: --> 2023-2024 Youth Leadership Application

2023-2024 Youth Leadership Application

APPLICATION DEADLINE IS JUNE 30, 2023

The Chamber Foundation, Inc.
One Civic Center Plaza, Suite 400
Poughkeepsie, NY 12601
845.454.1700 ext. 1025
Fax: 845.454.1702
foundation@chamberfdn.org

Program Sponsors: Gap Inc., State Farm, Royal Carting Service Co., and M & T Bank
Graduation Event Sponsor: DCH Wappingers Falls Toyota
Special Thanks To: Dutchess Community College
Student's name:
Address
Format: M/d/yyyy
Preferred method of contact *
Please check one.
Preferred Pronouns
Please check one.
The following questions are used only for statistical purposes:
Race and Ethnic Identification
THIS SECTION MUST BE COMPLETED BY A PARENT OR GUARDIAN
Parent(s)/Guardian(s) Name
Preferred method of contact *
Please check one.
Emergency Contact for Your Child
Fee Structure *
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. *
Please type your name - this acts as your digital signature.
Format: M/d/yyyy
PARENT OR GUARDIAN
Please type your name - this acts as your digital signature.
Format: M/d/yyyy