Student Influencer YouLead Registration Name First Name * Middle Name Last Name * E-mail Address * Name to appear on Certificate of Completion * Address * City * State * - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code * Neighborhood (Area of IRC) that best describes where you live * City of Vero Beach West Vero Beach Barrier Island Gifford Wabasso Sebastian South County Fellsmere Number of people living in your household (including all adults and children) * Annual household income * Cell Phone Number * Home Number Birthdate * Emergency Contact First Name * Emergency Contact Last Name * Relationship to Registrant * Emergency Contact Email * Special Needs or Allergies * Where Do You Lead Students (Check All That Apply) * VBHS SRHS MA SES Charter Homeschooled IR State College Treasure Coast Technical College Boys and Girls Club Big Brothers Big Sisters Youth Guidance Crossover Mission Gifford Youth Achievement Center Dasie Hope Hibiscus Children's Village Literacy Services of IRC Riverside Children's Theatre Vero Beach Museum of Art Church Youth Group Epic Mission Youth For Christ Performing and Visual Arts Recreational Sports Other (Describe) Describe Where Serve What best describes your role * Administrator Guidance Counselor Athletic Coach Teacher/ Professor Executive Director Program Director Youth Ministry Leader Youth Volunteer School Board Youth Related Board of Directors Youth Staff Parent Other Please Describe Your Role * Religious Affiliation (Check All That Apply) * VBHS Christianity Islam Judaism Buddhism Athiest Hinduism Other None Race / Ethnicity * American Indian or Alaska Native Asian African American or Black Native American or Pacific Islander Caucasian or White Indian Hispanic / Latino Other Gender Identity * Male Female Other Your personal Facebook link for the YOULead private Facebook invitation Please add a brief bio about yourself and share your future goals as they relate to leadership development * Student Influencer Agreement * By signing this application I agree to attend the duration of the You LEAD event on 10/20 at the iG Center from 8:30 a.m. to 3:00 p.m. I agree to complete pre-work assignment. I also give my permission for my photos to be used in JGF marketing (photo release). I am aware that data being used in research for future JGF grant applications. Signature * Student Influencer Signature Date * APPLICATION INFORMATION + Complete application by September 14, 2018 + Selection process by committee of leaders in IRC (rolling) + Formal acceptance (rolling) + Prework email week of September 21 + YouLEAD 10/20/18 from 8:30 a.m. to 3:00 p.m. Home About What We Do Community Complex Student Parking Football Parking Donate Get Involved Facebook Instagram Vimeo
