Balance Application Form

Youth Leadership Academy of Madison County is committed to providing leadership development and training to a group of motivated students. For this reason we have designed a new program to help YLA seniors prepare for a successful transition as they prepare to graduate and develop a sense of "balance" as they move forward in their life's journey.

Interested nominees should:

  • Demonstrate their leadership potential
  • Exhibit an interest in developing and growing as a person
  • Committee to FULL PARTICIPATION AND ATTENCANCE in all Balance activities
  • Maintain satisfactory academic, attendance and citizenship records
  • Tuition will be paid in full by 9/30/19

Application deadline is May 3, 2019.

First Name*
Please let us know your name.

Last Name*
Invalid Input

Preferred Name (for nametags)
Invalid Input

Street Address*
Invalid Input

Apt, Suite, Bldg
Invalid Input

City*
Invalid Input

State*
Invalid Input

Zip Code*
Invalid Input

Cell Phone*
Invalid Input

Home Phone
Invalid Input

Email*
Please let us know your email address.

Gender*
Invalid Input

Race*
Invalid Input

YLA does not discriminate on the basis of gender, race, religion or national origin.

Age*
Invalid Input

Birthdate*
/ / Invalid Input

School presently attending*
Invalid Input

Grade*
Invalid Input

The Balance program is available to 2018 YLA Graduates who will be High School Seniors in the Fall.

T-Shirt Size*
Invalid Input

ORGANIZATIONS AND ACTIVITIES
Please list any school, volunteer, religious, social, athletic or other activities in which you have participated. Explain what role you play in these organizations.
Invalid Input

WORK EXPERIENCE
List any job experience, full or part-time, and briefly tell what was involved.
Invalid Input

Will your employer make reasonable accommodations, so you can participate in Balance?
Invalid Input

Are you currently employed?
Invalid Input

If no, please explain the situation.
Invalid Input

If yes, where do you work?
Invalid Input

PARENT / GUARDIAN INFORMATION
Parent / Guardian Name(s)*
Invalid Input

Phone *
Invalid Input

Email
Invalid Input

Address*
Invalid Input

Parent(s) / Guardian(s) workplace, address and phone number. Please list both parents.*
Invalid Input

Alternate emergency name and phone number*
Invalid Input

PERSONAL PROFILE
What did you learn in YLA? How are you different because of your experience in YLA?*
Invalid Input

As an emerging leader, what leadership skills and traits would you like to improve on?*
Invalid Input

What do you hope to gain through this experience*
Invalid Input

How will participating in this program help you grow and succeed in college or your career?*
Invalid Input

Why do you want to participate in Balance?*
Invalid Input

If you could improve one thing in our community, what would it be and why*
Invalid Input

STATEMENT OF AGREEMENT
Balance Program Agreement
I understand that attendance at all Balance sessions is expected for graduation. * My behavior and participation will always reflect positively on Balance and my sponsoring agency. * Balance is a drug and alcohol free program, and I will abide by those standards during all Balance events. * I realize that I am a representative of all youth and I will at all times represent them honorably. * I authorize Balance to take appropriate measures if I cannot fulfill this agreement. *I agree with all of the above statements
*
Invalid Input

Tuition
I understand tuition is $250. $100 is due upon program acceptance and the balance is due on or before 9/30/2019.
*
Invalid Input

Medical/General Liability Release
I understand that my parent (or guardian) will be required to sign a medical release form prior to my participation in Balance.
*
Invalid Input

Photography Release
Youth Leadership Academy and Leadership Academy of Madison County (LAMC) staff, volunteers, and representatives routinely document activities associated with the Academy through photography, videography, audio recordings and other forms of media. I recognize that this media will be used in LAMC presentations, reports, and promotional materials, including on the LAMC/YLA website and social media sites. I hereby waive my child’s rights to privacy with respect to the use or release of the above-mentioned media. I further understand that no royalty fee or compensation of any character shall become payable to me or my child by the Leadership Academy of Madison County by reason of such use. I hereby release Leadership Academy of Madison County and its staff, volunteers, and representatives from any liability in its use or the use by others. I agree that the Leadership Academy of Madison County may use such photographs of my child with or without my child’s name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.
*
Invalid Input