2025 Leadership Academy Application Form

Student Name:*

First NameLast Name

Date of birth

Date

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

MaleFemale

E-mail*

example@example.com

Phone Number*

Grade Level (7-12)

Name of School

Participation Extracurricular Activities

Year of Graduation

Parent or Guardian

First NameLast Name

Parent or Guardian Phone Number

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

Parent or Guardian Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent or Guardian Email

example@example.com

Describe any leadership roles you have held in the past (e.g., in school, work, community organizations)

Why are you interested in participating in this leadership academy program?

What specific skills or knowledge do you hope to gain from this program?

How do you envision applying what you learn in this program to your personal and professional life?

What are your expectations from this training program?

How do you plan to contribute to the learning environment and support your fellow participants?

Do you have any dietary restrictions or special needs that we should be aware of? (e.g., allergies, accessibility requirements)

**Photography and Liability Release Statement**

By signing this application, I hereby give permission for [Youth Leadership Academy] and its representatives to take photographs and/or video recordings of my child/participant during academy activities. I understand that these images may be used for promotional purposes, including advertising and public awareness campaigns without further compensation. I grant [Youth Leadership Academy] the right to use, reproduce, and distribute these photographs and video recordings in any media formats now known or developed in the future.

I also acknowledge that [Youth Leadership Academy] is not responsible for any personal property damage or loss, including theft or any other form of damage that may occur during academy events. I agree to hold [Youth Leadership Academy], its staff, volunteers, and agents harmless from any claims, liabilities, or damages arising from such incidents.

I certify that I have read and fully understand the terms of this Photography and Liability Release Statement, and I voluntarily agree to these terms on behalf of myself and my child/participant.

Select Yes or No to the statement above:

Parent or Guardian Signature

Date Signed

Date