Student YouLead Registration Order Number First Name * Middle Name Last Name * E-mail Address * Name to appear on Certificate of Completion * Reference Name (Administrator / Teacher / Coach /Program Director / Youth Minister) * 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 * Student Cell Phone Number * Student Home Number Student Birthdate * Emergency Contact First Name * Emergency Contact Last Name * Emergency Contact Email * Special Needs or Allergies * Current Grade * High School * VBHS SRHS Master's Academy St. Edward's School Charter Homeschool Virtual Gender Identity * Male Female Other (Describe) Describe Religious Affiliation (Check All That Apply) * 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 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. 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 * Current Leadership Involvement (Check All That Apply) * Athletics / Sports Student Government Performing Arts Visual Arts Youth Ministry / Church Clubs Educational Team After School Program Other (Please Describe) Describe Student Agreement * By signing this digital agreement, I agree to attend YOULead Institute Student Leadership Challenge for the duration of the event on 10/20/18 at the iG Center, from 8:30 am to 3:00 pm. I agree to complete pre work assignment. Signature * Student Signature Date * Parent or Guardian Agreement * By signing this application I agree to give the above child permission to attend the YouLEAD event on 10/20 at the iG Center from 8:30 a.m. to 3:00 p.m. I agree to support the student with his/ her pre-work assignment. I also give my permission for the above to student's photos to be used in JGF marketing (photo release). I am aware and agree to my child's data being used in research for future JGF grant applications. Parent or Guardian Signature * Parent or Guardian Signature Date * Home About What We Do Community Complex Student Parking Football Parking Donate Get Involved Facebook Instagram Vimeo
