YLF

Chattanooga-Hamilton County Medical Society and Medical Foundation of Chattanooga

2025 Youth Leadership Forum on Medicine Application

The Forum is offered to rising high school seniors and 2025 high school graduates interested in careers in medicine. The forum seeks to increase student interest in the medical profession and acquaint them with resources to pursue medicine.

Program Dates: June 9-12, 2025
APPLICATION DEADLINE - April 25, 2025
Name
Street Address
City
State
Zip
Cell Phone
Email
example@example.com
Mailing Address, if different
Name of School
Current Grade Level
GPA
Date of Birth

MonthDayYear
Date
Sex

FemaleMaleOther
Father's Name
Father's Address, if different
Mother's Name
Mother's Address, if different
Emergency Contact
Relationship
Street Address
Cell Phone
Work Phone
Personal References
Please list the name, job title, relationship, and phone numbers for two personal references.
REFERENCE 1
Relationship
Job Title
Phone Number
REFERENCE 2
Relationship
Job Title
Phone Number
Nomination by HS principal, guidance counselor, teacher, youth program or civic leader, employer, pastor, etc.
Name
Title
Email
example@example.com
Phone Number
School or Organization
LETTERS OF RECOMMENDATION ARE HIGHLY SUGGESTED.

Recommendation letters may be provided by a HS principal, guidance counselor, teacher, youth program or civic leader, employer, pastor, etc. Please have recommendation letters emailed to Kevin@chattmd.org
List extracurricular activities, leadership positions, personal achievements, awards, or recognition in the last three years. How has your participation in these activities been of benefit to you?
What do you hope to learn by participating in the Youth Leadership Forum on Medicine?
Employment | Volunteer History
List any job experience, paid or volunteer, and briefly explain.
Do you currently have a part-time job?

YesNo
If yes, how many hours per week?
If yes, would your job interfere with your attendance?

YesNo
It is the policy of this organization to provide equal opportunities without regard to race, color, religion, national origin, gender, sexual preference, age, or disability.

Thank you for your interest in participating in the 2025 Youth Leadership Forum on Medicine.
Agreement | Signature

Full attendance by each participant is essential. If selected, I am committed to attend and participate in each of the program sessions. By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if I am accepted in the program, any false statements, omissions, or other misrepresentations made by me on this application may result in my immediate dismissal.
Sign Name

Clear
Date

MonthDayYear
Date
Should be Empty:

APPLICATION DEADLINE - April 25, 2025

Personal References

Nomination by HS principal, guidance counselor, teacher, youth program or civic leader, employer, pastor, etc.

Employment | Volunteer History

Agreement | Signature