2022-2023 Youth Leadership Application – Leadership South Bend – Mishawaka

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2022-2023 Youth Leadership Application

Students who are rising sophomores and juniors may be nominated or apply directly to the Youth Leadership program. The application opens April 18, 2022. Nominated students will be notified and invited to submit an application. Selections and interviews began Aug 1st.

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Today's Date *

Your Name *

First

Last

Your Contact Email *

Your Gender Identity *

Your Race/Ethnicity *

Your Home Address *

Address Line 1

Address Line 2

City

State

Zip Code

Name of Parents/Guardian *

First

Last

Parent/Guardian Home Phone # *

Parent/Guardian Work Phone #

Parent/Guardian Email *

Additional Parent/Guardian Email

Parent/Guardian Employer *

Please check this box if your parent needs communications in a language other than English.

Does your parent or guardian have the same address as you? *

Yes
No

Please list any family members that are affiliated with Youth or Adult Leadership.

School Experience

School Presently Attending *

Who nominated you for the Youth Leadership Program? (if applicable)

Your Grade in 2022-2023 *

How long have you been at this school? *

What is your cumulative GPA? *

Organizations and Activities

Please list, in order of importance to you, up to five school, volunteer, religious, social, athletic or other activities/organizations in which you have participated during high school.

1. Activity/Organization *

List your grade in school and your leadership responsibility involved.

2. Activity/Organization

List your grade in school and your leadership responsibility involved.

3. Activity/Organization

List your grade in school and your leadership responsibility involved.

4. Activity/Organization

List your grade in school and your leadership responsibility involved.

5. Activity/Organization

List your grade in school and your leadership responsibility involved.

List special awards, honors or recognition for academic, school or community-related activities you have received during high school.

Work and Volunteer Experience

Do you currently have a part-time job or volunteer position? *

Yes
No

List any part-time job experience, paid or volunteer, and briefly tell what was/is involved.

General Information

1. Using a few phrases or adjectives, describe yourself. *

2. What do you consider the most rewarding experience you have had? *

3. What prompted you to apply to Youth Leadership and what do you hope to gain if you are accepted? *

4. What are three of the issues facing your community that are most important to you? *

5. Identify a leader you respect and why. *

6. Youth Leadership strives to select a class that is representative of our community and of its diverse perspectives. To help us achieve this goal, please explain what unique perspectives you bring to the class or how you will contribute to the diversity of the class. *

Program Consent

1. I understand that I must attend all seven scheduled Program Days, orientation, the retreat, and commencement in order to graduate from this program. (Note: School attendance credit will be granted for each class session attended. This is an excused absence.)
2. We have checked the program calendar dates on the Leadership South Bend - Mishawaka website before submitting candidacy and understand that the attendance requirements involve missing eight days of school.
3. If I am accepted into Youth Leadership, I understand the honor of participating in this program and will commit to full participation.
4. During Youth Leadership, photographs will be taken. I consent to the use of my photograph in any literature involved with this program.

Signature of Participant *

Signature of Parent or Guardian