Spring 2024 Agents & Advocates Leadership Fellowship
February 5th - April 27, 2024
About the Leadership Fellowship
Chester Leaders in Liberation is a fellowship program for 8th, 9th, and 10th grade students that seeks to prepare the next generation of leaders to create change in their communities. Fellows meet twice a week during the academic year and select Saturdays for events and field trips. The Fellowship includes opportunities to engage community stakeholders, leaders, and elected officials within the City of Chester. Ultimately, Fellows will develop and exercise their leadership skills by creating a change-oriented project aimed at enhancing the wellbeing of Chester residents and its surrounding communities.
Notes: The Fellowship will be an unpaid opportunity for the 23-24 Agents & Advocates Leadership Fellowship
Student Name
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First Name
Last Name
School
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Grade
*
Please Select
8th Grade
9th Grade
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Student Email
*
example@example.com
Cell Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Gender (optional)
Pronouns
Please Select
She/her/hers.
He/him/his.
They/them/theirs.
Ze/hir/hirs.
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What is one thing about Chester that you are proud of? What is one aspect of Chester that you would like to be a part of changing?
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List up to three significant extracurricular or leadership activities or roles you're involved in. Describe one, and how it has impacted you.
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What interests you about becoming an Agent and Advocate Fellow this year? What do you hope to gain from this experience?
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What else would you like the selection committee to know about you?
I certify that the information provided in this application is accurate and truthful to the best of my knowledge. I understand that any false or misleading information may result in disqualification from the Leadership Fellowship Program.
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Please provide a Letter of Support from an adult other than your parent/guardian who can speak to your character, leadership potential, or involvement in community service or extracurricular activities.
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Reference Name:
*
Phone Number
Relationship to Applicant
Email Address
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Parent/Guardian Contact
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Daytime Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Evening Phone (Secondary Number)
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Emergency Contact #1
*
First Name
Last Name
Daytime Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Evening Phone (Secondary Number)
Please enter a valid phone number.
Format: (000) 000-0000.
Medical Information:
Doctor's Name:
Doctor's Number
Medical Insurance Provider:
Policy Number
Known Allergies or Medical Conditions; Is there anything we should understand in regards to your child's health on a day to day basis?
Signature
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Authorized Pickup Persons: (Please list the names of individuals authorized to pick up the student from the program, if different from the emergency contacts listed above.)
I, the undersigned, certify that the information provided on this Emergency Contact Information Form is accurate and up-to-date. In case of an emergency, I authorize program staff to seek medical treatment for my child, as deemed necessary, and to contact the emergency contacts listed above. I understand that every effort will be made to contact the parents/guardians first.
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I understand that any audio, photographs or videos taken of participants by the 4 Circles Beyond staff during the program may be used for Agents & Advocates Leadership Fellowship promotional use both in print and electronic form on 4 Circles Beyond, Inc. and program affiliate websites. I give the camp’s staff permission to use images of my child for this purpose.
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