YOUTH LEADERSHIP INTEREST & REFERRAL FORM

Welcome to the Youth Leadership Program Interest form at The House of Darla!

This is a merit, character, and leadership program designed to empower, encourage, and inspire students to be leaders while gaining essential life skills. As part of this experience, students will take the lead and develop hands-on leadership skills by stepping into roles that shape and drive our You(th)-led social enterprise.

Participants will gain real-world experience, mentorship, and opportunities for personal and professional growth. This is a chance to build both personal and professional profiles, be part of something unique, and have access to creating impactful projects. Students will strengthen their leadership abilities, take initiative, and develop skills that will set them apart in school, careers, and beyond.

Beyond leadership, students will have access to exclusive benefits and perks, including skill-building workshops, networking opportunities, and recognition for their contributions. Through community service and organizational involvement, they will connect with like-minded peers, have fun, and give back in meaningful ways.

This program is more than just leadership—it’s about becoming the change, making an impact, and preparing for the future.

If you or a student you know is ready to step up, grow, and lead, fill out this form to apply or refer someone today! 🚀💡✨

Please note:

There is an application process and interview for selection.
Participation requires commitment and strong behavior/ growth mindset.
Acceptance can be rescinded or revoked based on conduct or commitment levels.
We offer 1:1 and group mentorship (via state agency if applicable).

Complete this form to sign up or refer a student.

I am*

an interested candidate ( student/youth)Parent/GuardianReferring Agency/IndividualOther

Name ( of student/participant)*

First NameLast Name

Gender*

Current Age*

Date of Birth

Date

Ethnicity*

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Email*

example@example.com

Emergency Contact Name*

First NameLast Name

Emergency Contact Number*

Emergency Contact Email*

example@example.com

Relationship to Applicant *

Name of Individual filling out the form*

First NameLast Name

Referrer Email *

example@example.com

Referrer Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

School Name ( If not in school enter N/A)*

Current Grade*

How did you hear about us?*

Prior participation in HOD Cohorts or Programming?*

YesNoHODxSWG

if yes, when did you participate

Check all that apply:*

If selected, are you able to attend Youth Leadership/Programming at The Space ( 296 Park avenue, Bridgeport, CT)*

YesNoOther

How much time can you dedicate to the program*

What social media do you use?( check all that may apply)*

Are you interested or elijible for 1:1 mentorship or group mentorship ( state agency)*

YesNoOtherN/A

Agency Name*

Eligible hours per week?

Eligible hours per week?( #)*

enter 0 if N/A

Eligible hours per month?(#)*

enter 0 if N/A

Do you have any behavioral issues or areas you need to work on?*

if no enter N/A......if answering on the behalf of someone via referral please enter

Have you ever been removed from a program for behavioral issues?*

YesNoUnsureOther

Reason for interest in the Youth Leadership Program*

I understand that this program is based on merit, character, and leadership. I commit to being an active participant, demonstrating responsibility, and maintaining positive behavior. I acknowledge that participation is subject to an application process, interview, and can be rescinded if necessary*

YesNo

YOUTH LEADERSHIP INTEREST & REFERRAL FORM

Education & Eligibility

Commitment & Availability

Behavioral & Program Readiness

Agreement & Submission