DEADLINE: September 29, 2017

Please e-mail completed application to , or mail to Uli Imhoff Heine, PCI 5151 Murphy Canyon Rd #320, San Diego, CA92123

Global Youth Leadership Program Application

SECTION 1: REGISTRATION FORM

Youth Participant information:

First Name:______Middle: ______Last:______

Grade: Fall 2017 (circle one) : 9th 10th11th 12th

CurrentSchool:______

Birth Date (Month/Date/Year):______

Street Address: ______

City:______State:______Zip code:______

Home Phone:______

Cell Phone:______

Email Address:______

Parent/ Guardian Information

Parent Name:______

Parent Cell Phone:______

Parent Home Phone (If different from Above):______

Parent Email Address: ______

Parent Street Address (if different from above):______

Emergency Contact Name:______

Emergency Contact Cell Phone:______

Emergency Contact Home Phone (If different from Above):______

Emergency Contact Email Address:______

Health Information:

Physical Limitations:______

Dietary restrictions:______

Please list any known allergies:______

Please list any other health concerns you may have:______

SECTION 2: Volunteer Work

Please describe any volunteer work you have participated in:

Volunteer Work #1:

Organization:______

Date Began:______

Date Completed:______

Duties Performed:______

Position:______

Volunteer Work #2:

Organization:______

Position:______

Date Began:______

Date Completed:______

Duties Performed:______

Volunteer Work #3:

Organization:______

Position:______

Date Began:______

Date Completed:______

Duties Performed:______

SECTION 3: SHORT ANSWER QUESTIONS

Open ended questions:

  1. Why do you want to become a member of the PCI Global Youth Leadership Program?
  1. What do you hope to gain from this experience?

PCI Global Youth Leadership Scholarship Form

PCI Global Youth Leadership Scholarship Form

Please Note:

  1. All financial assistance will be awarded on the basis of need. This is not a merit based scholarship.
  2. Scholarships of $50-$425will be awarded depending on financial need.

Please answer the questions below and email form to: Uli Imhoff Heine at

Child/Children Name(s):

Name of Applicant (Parent):

Please indicate the amount (out of the full $425contribution) you are able to pay:______

Parent reason for registering child/children to participate in the PCI Global Youth Leadership Program:

Please explain how you believe your child will benefit from the PCI Global Youth Leadership Program:

Please describe your financial need.

Is there anything else you would like us to keep in mind as we consider your scholarship request?