Preferred Name (for nametags)
Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Month 01 02 03 04 05 06 07 08 09 10 11 12
Year 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
School presently attending
Small Medium Large XL XXL
How did you hear about YLA?
PARENT / GUARDIAN INFORMATION
Parent(s)/Guardian(s) workplace, address and phone number. Please list both parents.
Alternate emergency name and phone number
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.
List any job experience, full or part-time, and briefly tell what was involved.
Are you currently employed?
If yes, where do you work?
Will your employer make reasonable accommodations, so you can participate in YLA?
If no, please explain the situation.
Describe three qualities which best illustrate your leadership potential.
What two leadership traits do you hope to improve most through YLA
What is the biggest issue high school students are wrestling with today
Why do you want to participate in YLA
How did you hear about this program?
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
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.
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.
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).