Youth Leadership Custer County

Application

Class I

Mission

To develop community leaders who will strengthen and transform the Custer County area by preparing participants to assume increasingly responsible leadership roles in their personal, professional, and academic lives.

Program Description

Effective leaders are essential in today’s society, and serve as models of achievement, accomplishment, and triumph. The intent of Practical Leadership is to offer area high school students the opportunity to learn and practice essential leadership skills in a structured setting, then encourages students to apply those skills in leadership opportunities in their communities.

Requirements

Applicants must be high school sophomores or juniors or home-schooled equivalent.

Applicants must attend school in Custer County.

Class members must attend each session in its entirety.

Class members must agree to abide by all Leadership Custer County policies and procedures.

Application process

  1. Applications may be turned in to the student’s high school principal or guidance counselor. Applications will be collected from the schools by September 6.
  2. Applications must be typed and complete to be considered.

Please carefully read the application process instructions on page one before completing the application.

Applicant Name

LastFirstMiddle Initial Preferred Name

Mailing Address

Address City State Zip Code

Home Phone ______Cell Phone Applicant Email

Parent/GuardianCell Phone ( )

Parent/Guardian Email______

High School Name ______High School GPA ______

School Contact /Counselor ______School Contact Email

T-Shirt Size

Optional Information: Youth Leadership Custer County does not discriminate based on race, ethnicity, sex, creed, national origin or disability. This information is not required. It is requested to facilitate our goal of assembling a diverse class.

Gender:FemaleMale

Race/Ethnicity: American Indian Asian African American

Hispanic White Other: ______

I found out about Youth Leadership Custer County:CEDC business or member (name)______school principal or counselor newspaper other, please specify

______

Please let us know the leadership roles you have held while involved in organizations or activities both in your school and/or community. These should be in order of importance, listing up to five school, social, athletic, religious, community service, scouting or other activities and organizations in which you have participated.

1.

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5.

Youth Leadership Custer County

Commitment Form

This form must be signed by all three parties as indicated and returned with the application by the deadline.

Applicant Name (please print)

I understand that a student who is admitted to the Youth Leadership Custer County program is given a space in the program that is then not available to other applicants. Consequently, students who apply for the program MUST intend to accept admission and participate fully in the Youth Leadership Custer County program.

I have reviewed the completed application packet and support this nomination.

______

ApplicantDate

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Applicant’s Parent/GuardianDate

______

Applicant’s School PrincipalDate

Youth Leadership Custer County

Consent Form

This Consent form is executed by(Participant) to Youth Leadership Custer County, its directors, officers, agents, volunteers and employees, including the directors, officers, agents, volunteers and employees in the Youth Leadership Custer County program.

Consent for Transportation

I give permission for my child to be transported in a motor vehicle driven by a Youth Leadership Custer County volunteer while participating in Youth Leadership Custer County activities, for the duration of the program. I understand that my child is expected to follow all applicable laws regarding riding in a motor vehicle and is expected to follow the directions provided by the driver and/or other adult volunteers.

Consent for Reproduction of Photographs and Voice

In the course of the program, newsletters, public service announcements, newspaper and magazine articles, web site features and videos may be used. Participant gives to Leadership Custer County, its nominees, agents and assigns unlimited permission to use, publish and republish for purposes of advertising and trade for such use as it may determine, information and reproduction of Participant’s likeness (photographic and otherwise) and voice related to participation in Youth Leadership Custer County.

Consent for Medical Treatment

In the event that medical treatment is necessary, Participant gives to Leadership Custer County, its nominees, agents and assigns permission to obtain treatment at a medical facility.

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Signature of Participant

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Signature of Parent or Legal Guardian of Participant

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