fbpx

Meet & Greet - Meet the LAMC class of 2020 at Harrah's Hoosier Park Racing & Casino. FREE to attend. Reservations required. RSVP TODAY

YLA Registration Form

Please let us know your name.

Invalid Input

Invalid Input

Invalid Input

Invalid Input

Invalid Input

Invalid Input

Invalid Input

Please let us know your email address.

Invalid Input

Invalid Input

/ / Invalid Input

Invalid Input

Invalid Input

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

Invalid Input

Invalid Input

Invalid Input

Invalid Input

PARENT / GUARDIAN INFORMATION
Invalid Input

Invalid Input

Invalid Input

Invalid Input

Invalid Input

Invalid Input

ORGANIZATIONS AND ACTIVITIES
Invalid Input

WORK EXPERIENCE
Invalid Input

Invalid Input

Invalid Input

Invalid Input

Invalid Input

PERSONAL PROFILE
Invalid Input

Invalid Input

Invalid Input

Invalid Input

Invalid Input

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

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.
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

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).
Invalid Input