YLA Registration 2018

First Name*

Please let us know your name.

Last Name*

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Preferred Name (for nametags)

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Street Address*

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City*

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State*

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Zip Code*

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Cell Phone*

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Email*

Please let us know your email address.

Home Phone

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Gender*

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Birthdate*

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Age*

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Race*

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

School presently attending*

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Grade*

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T-Shirt Size*

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How did you hear about YLA?

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PARENT / GUARDIAN INFORMATION

Parent/Guardian Name(s)*

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Address*

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Phone *

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Email

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

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Alternate emergency name and phone number*

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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.

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WORK EXPERIENCE

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

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Are you currently employed?

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If yes, where do you work?

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Will your employer make reasonable accommodations, so you can participate in YLA?

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If no, please explain the situation.

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PERSONAL PROFILE

Describe three qualities which best illustrate your leadership potential. *

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What two leadership traits do you hope to improve most through YLA*

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What is the biggest issue high school students are wrestling with today*

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Why do you want to participate in YLA*

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How did you hear about this program?*

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

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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

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I agreeI do not agree

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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 Youth Leadership Academy.

*

I agree

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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.

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I agreeI do not agree

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Scholarship
Please check box if you would like to be considered for an income based scholarship (limited funds for scholarships available, must provide evidence of income if accepted to be considered for a scholarship on a sliding scale fee).

Scholarship

I agree

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