YLA Application Form

Youth Leadership Academy of Madison County is committed to providing leadership development and training to a group of motivated students who represent a diversity of racial, ethnic and socio-economic groups in Madison County.

Interested nominees should:

  • Demonstrate their leadership potential for community trusteeship.
  • Exhibit interest in community service
  • Attendance at camp is mandatory. (July 14-16, 2017)
  • Commit to FULL PARTICIPATION AND ATTENDANCE in all YLA programs. Participants who fail to attend more than one (1) session are at risk of not receiving their certificate of completion.
  • Maintain satisfactory academic, attendance and citizenship records.
  • Tuition will be due upon acceptance in the program.

A student recommendation needs to be completed by someone other than a family member. Download the Student Recommendation Form or it may be completed online.

Application deadline is May 5, 2017.

Please complete the following application

First Name*
Please let us know your name.
Last Name*
Invalid Input
Preferred Name (for nametags)
Invalid Input
Street Address*
Invalid Input
City*
Invalid Input
State*
Invalid Input
Zip Code*
Invalid Input
Cell Phone*
Invalid Input
Email*
Please let us know your email address.
Home Phone
Invalid Input
Gender*
Invalid Input
Birthdate*
/ / Invalid Input
Age*
Invalid Input
Race*
Invalid Input
School presently attending*
Invalid Input
Grade*
Invalid Input
T-Shirt Size*
Invalid Input
How did you hear about YLA?
Invalid Input
PARENT / GUARDIAN INFORMATION
Parent/Guardian Name(s)*
Invalid Input
Address*
Invalid Input
Phone *
Invalid Input
Email
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
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
Are you currently employed?
Invalid Input
If yes, where do you work?
Invalid Input
Will your employer make reasonable accommodations, so you can participate in YLA?
Invalid Input
If no, please explain the situation.
Invalid Input
PERSONAL PROFILE
Describe three qualities which best illustrate your leadership potential. *
Invalid Input
What two leadership traits do you hope to improve most through YLA*
Invalid Input
What is the biggest issue high school students are wrestling with today*
Invalid Input
Why do you want to participate in YLA*
Invalid Input
What do you hope to gain through this experience*
Invalid Input
If you could improve one thing in our community, what would it be and why*
Invalid Input
STATEMENT OF AGREEMENT
I understand that attendance at all YLA sessions is expected for graduation. * My behavior and participation will always reflect positively on YLA and my sponsoring agency. * YLA is a drug and alcohol free program, and I will abide by those standards during all YLA events. * I realize that I am a representative of all youth and I will at all times represent them honorably. * I authorize YLA to take appropriate measures if I cannot fulfill this agreement. *I agree with all of the above statements
*
Invalid Input