Roane County Youth Leadership (RCYL)

Roane County Youth Leadership (RCYL)

Instructions, Requirements, Consent Form and Application
Instructions: The application must be completed entirely before the deadline date of February 15th to be considered for the Roane County Youth Leadership Program. If you have questions you may phone the Roane County Chamber of Commerce at 865-376-5572 or email roaneyouthleadership@gmail.com

Read application carefully as failure to complete correctly will disquality the student.

Required Information:

1. Parent and Student Consent Form

2. Application

3. Educator Reference Form - to be printed and completed by teacher or guidance counselor. You can download this form on our website linked here.

4. Principal Recommendation Form - to be printed and completed by principal. You can download this form on our website linked here.

5. A short essay. Details on essay page below.

6. A wallet size school photo or other head shot - Please email this to roaneyouthleadership@gmail.com or mail it to Roane Youth Leadership, 1209 N. Ky. St. Kingston, Tn. 37763. Please put student's name and school on the back side of the photo if mailed.

Requirements to complete the program include:

1. Attendance at the one week camp held during the summer, usually the first full week after current school year is over. (this is subject to change and the exact dates and time to be announced)

2. Attending 2 Roane County civic meetings. (Ro. County Commission, Ro. Co. School Board or a City Council meeting) after summer camp but no later than October 31st.

3. Attending after school sessions that will be held after school is back in session. (exact dates and time to be announced) They are typically on Mon., Tues., or Thursday and start around 6:00 PM lasting for 1 - 2 hours.

4. Work with other RCYL participants to complete a community service project which must be complete prior to graduation.

In order to graduate the RCYL program, the participant must be present at four of the five days of the camp, (Monday is mandatory) attend the civic meetings as well as all of the after school meetings. Graduation will occur in the fall. PLEASE KEEP IN MIND YOUR CURRENT ACTIVITIES, SPORTS, JOBS, ETC. THAT YOU ARE INVOLVED IN AS TO WHETHER YOU CAN COMPLETE THE REQUIREMENTS FOR THE PROGRAM.
Acknowledgment and Consents (please check signifying agreement)*

If selected, I commit to attending the summer camp, civic meetings, after school sessions, work on a community service project and attend the graduation.I understand that I will pay a participation fee of $40.00I give my permission for my photograph to be used on the RCYL website, the Newspaper, in marketing related materials and/or on social media.
I certify that the answers given herein are true and that I am a high school student who will be in either the 10th, 11th or 12th grade in the upcoming/next academic year in Roane County, Tennessee.
I First Name* Last Name* the parent and legal guardian of First Name* Last Name* have read the information regarding the Roane County Youth Leadership Program and am willing to have my child participate if selected. RCYL, and all their agents have my full permission and consent to transport my child by appropriate transportation in connection with all sessions of RCYL during the year in which he/she is a participant.

I hereby release, indemnify, and hold harmless RCYL, their agents or any individuals involved in the planning, organization or presentation of Roane County Youth Leadership for any accident, injury, illness, or damage whatsoever related to the above-mentioned student’s participation in any activity or session of Roane County Youth Leadership.
Parent/Legal Guardian: (Print Name) *

First NameLast Name
Parent Signature*

Clear
Date*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number*
Please enter a valid phone number.
Cell Phone Number*
Please enter a valid phone number.
Student Signature*

Clear
Date*

MonthDayYear
Date
Participants will be notified if accepted by March 31st.

AFTER SUBMISSION OF THIS FORM YOU WILL RECEIVE A COPY OF THE COMPLETED FORM VIA EMAIL. IT IS SUGGESTED THAT YOU PRINT A COPY OF YOUR COMPLETED APPLICATION AS A REMINDER OF YOUR REQUIREMENTS IF SELECTED.
Roane County Youth Leadership (RCYL) Application
I attend school at*
Current grade:*

9th10th11th
Student Name*

First NameMiddle NameLast Name
Preferred Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number*
Please enter a valid phone number.
Student Cell Phone Number*
Please enter a valid phone number.
Student E mail (do not list school email)*
example@example.com
Birth Date*

MonthDayYear
Date
Student Gender:*

MaleFemale
Race/Ethnicity (Optional)
Parent Email*
example@example.com
Parent or Guardian’s Name*

First NameLast Name
Parent or Guardian Daytime Phone Number(s) in case of emergency.*
Please enter a valid phone number.
Parent or Guardian Daytime Phone Number(s) in case of emergency.
Please enter a valid phone number.
Student Allergies:*
Food Allergies/ Dietary Restrictions/Special Accommodations Requested:*
Medical Conditions? If Yes, please contact RCYL with full details. roaneyouthleadership@gmail.com*

YesNo
Extra-Curricular Activities: (sports, band, cheer, etc.)*
Will student be driving themselves to program day site:*

YesNo
T-Shirt or Polo Shirt Size (Unisex):*
(Small thru XXL)
How did you hear about the program?*
REFERENCES REQUIRED - SCHOOL (teacher or guidance counselor) AND PRINCIPAL RECOMMENDATION forms can be found on the Leadership Roane County Webpage. You can either print and give these pages to them or ask they print them. These forms must be returned by the deadline date of Feb. 15th for you to qualify.
Brief Essay Page

to be completed by the student
What do you hope to gain as a participant of Roane County Youth Leadership?*
How can young people be more effective leaders in Roane County?*
Using a few adjectives and phrases, describe yourself and what makes you unique?*
RCYL is investing in your leadership development by providing this program for you. What do you hope to give back to Roane County during the next year? Over the next 10 years?*
Describe an instance when you observed someone in a leadership position who did NOT use good leadership skills. How would using better leadership skills have made the outcome more positive?*
Describe someone who you think displays very good leadership skills and why?*
Other Comments:*
Should be Empty:

Roane County Youth Leadership (RCYL)

Roane County Youth Leadership (RCYL) Application

Brief Essay Page