Youth Leadership Summit 2017
July Application Form
(Application Deadline: First come, first served)
Applicant General Information:(Please print with blue or black ink)
Name:
Address:
City: Zip:
Phone Number:
Email:
School: Grade:
Birth Date: Gender: Male Female
Do you have a disability? Yes No Type of Disability:
Do you have an IEP or 504 plan? IEP 504 plan Neither
After you graduate, do you plan to:
Go to a university or technical college? Yes No
Look for a job? Yes No
The Youth Leadership Summit will be held July 10-14 at the Mequon Nature Preserve
July10th -14th8200 W. County Line Rd., MEQUON
Parent / Guardian Name(s):
Address:
City: Zip:
Phone Number:
Email:
Emergency Contact Same as Above
Name: Phone Number:
Additional Information:
Please answer the following questions in 2-3 sentences each. If you need more space, feel free to attach an additional page.
1. Why would you like to be part of the Youth Leadership Summit?
2. What is the main thing that comes to mind when you think about your future?
3. What would you like to gain or learn from the Youth Leadership Summit?
4. What are your hobbies/interests outside of school?
5. What kind of job/career would you like to have?
Accommodations or Assistance:
Please let us know about any accommodations or assistance that you will need to participate in the Youth leadership Summit. Participants are responsible for their own personal care workers.
Assistance with reading or writing
Materials in large print
Sign language interpreter
Foreign language interpreter Language:
Dietary restrictions (i.e. allergies)
Other accommodation:
Bus tickets to and from the Youth Leadership Summit
Is there anything else we need to know about you?
In order to be considered for the Youth Leadership Summit you must:
Fill out every part of the application
Be able to attend the entire Summit
(July 10-14, 10:00am – 4:00pm)
Have a teacher or counselor fill out the recommendation form
Teacher/Counselor Recommendation Form:
Instructions for Students: Fill out the application and then ask a teacher or counselor to fill out this page. You or your teacher can mail the complete application.
Instructions for Teachers/Counselors: Each student who applies to the Summer Youth Leadership Summit must get a recommendation from one of their teachers or counselors at school. Your student has selected you to do this for him/her. Please take some time and fill out this form thoughtfully. This recommendation form is an important part of the application assessment and will be taken strongly into consideration when participants are chosen. The student must fill out pages 1 and 2 of the application, and then have you complete the Recommendation Form.
When you have finished, please send the entire application to:
Grant Heffelfinger
IndependenceFirst
540 S 1st Street
Milwaukee, WI 53204
Phone: 414- 226-8367
Fax: 414-291-7525
Email:
Name of Applicant:
Your Name:
Relationship to applicant:
Phone Number: E-mail:
How long have you known applicant?
Please answer the following questions / Below Average / Average / Above Average1. Ability to work with others
Comment:
2. Level of motivation
Comment:
3. Reliability (meeting obligations, schedules)
Comment:
4. School or program attendance
Comment:
5. Social qualities (friendliness, cooperation, tact)
Comment:
6. Emotional stability (behavior consistency)
Comment:
Please use this space to write a few sentences as to why this applicant should be accepted into the Summer Youth Leadership Summit 2017.
IndependenceFirst
Youth Leadership Application
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