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Youth Program Application
Contact Information
Name
*
First Name
Last Name
Name as it should appear on nametag/preferred name:
*
Email
*
Verify Email
*
Address
*
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Date of Birth
*
(mm/dd/yyyy)
What grade will you be going into the next school year (2024-25)?
*
select one
11th Grade (Junior)
12th Grade (Senior)
I graduated
Home Phone
Cell Phone
*
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Daytime Phone (in case of emergency)
*
Parent/Guardian Email
*
Verify Email
*
High School
*
Days absent during the last three school semesters
*
Shirt Size
*
select one
XS
S
M
L
XL
XXL
XXXL
Dietary Restrictions
What is your favorite snack?
*
Please list up to 4 areas you would be interested in shadowing (examples: health care, engineering, accountant, PR Marketing, trades etc.)
*
How did you find out about the Leadership Geauga County Youth Leadership Institute?
*
select one
At school
On the web
Social media
From a friend
References
School Reference Name
*
First Name
Last Name
Address
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Email
*
Verify Email
*
Phone
*
Community Reference Name 1
*
First Name
Last Name
Address
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Email
*
Verify Email
*
Phone
*
If you are currently working, list the name of the name of your employer (business) and how many hours you work each week.
Extracurricular Activities at School
Please list, in order of importance to you, up to four extracurricular activities in which you are involved at school (if applicable).
Please include: Activity/Organization - Your Leadership Position - Hours/Week - Years Involved
Essay Question
Please describe why you are applying to the Leadership Geauga Youth Leadership Institute and what you hope to gain from the experience.
*
Scholarship Application
Leadership Geauga has a limited amount of financial aid available to individuals who could not participate in the program without subsidy. These funds are raised through corporate gifts, grants, and other annual fund raising initiatives.
Would you like to apply for a scholarship?
*
Yes
No
Reason for the request (a reason is required)
Amount Requested
How will the remainder of the tuition be paid? (All participants must pay at least $100)
