LP26' - 1st Year Application
| Murrells Inlet, SC |
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Personal Information
Name
*
First Name
Last Name
Gender
*
Male
Female
Birthdate (MM-DD-YYYY)
-
Month
-
Day
Year
Date
Phone Number
*
E-mail
*
Ex: JohnDoe123@gmail.com
Ethnicity
*
Asian
African American
Hispanic or Latino
White
Other
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Background Info
Parent/Guardian Name
*
First Name
Last Name
Email
*
Ex: JohnDoeMama123@gmail.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Details
Staff Point Person
*
Please Select
FSC Men - (Graham, Jacob)
FSC Women - (Kristin, Brynlee)
SEU Men - (Jaxon, Craig, David)
SEU Women - (Victoria, Maddie)
School
*
Please Select
Florida Southern College
Southeastern University
Polk State College
University of South Florida
Poly Tech University
Other
Year in School
*
Please Select
Freshman
Sophmore
Junior
Senior
Graduate
Expected Graduation
*
i.e May 2025, December 2024, etc.
Major
*
i.e Marketing, Spanish, Nursing, etc.
Please Select any Dietary Restrictions and/or allergies you Have
*
N/A
Dairy Free
Gluten Free
Other
Do you have a medical, physical, or psychological condition for which you are currently being treated? If yes, please explain
*
Do you consistently take any medications or prescriptions? If yes, please explain.
*
Any Allergies we should know about?
*
Shirt Size
*
Please Select
Small
Medium
Large
X-Large
XX-Large
XXX-Large
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Personal Reflection
Please reflect on your experience unto this point
Briefly describe your involvement with Campus Outreach.
*
What do you believe is the purpose of the Leadership Project?
*
What are some reasons you desire to be a part of the Leadership Project?
*
What are some reasons you desire to be a part of the Leadership Project?
*
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Verification
Reference Name
*
Reference Phone Number
*
Please enter a valid phone number.
Relationship to Reference (I.e. friend, mentor, employer, family member, etc.)
*
If accepted, do you commit to attend Support Raising Training and work towards securing 100% of your financial goal by the end of LP?
*
Yes
No
Other
Your submission of this application affirms that you have, to the best of your knowledge, honestly and fully answered all questions. In the event the above information should be found to be untrue, it could result in forfeiting the opportunity to be a part of the Leadership Project.
*
I Agree
I Disagree
Other
Please add a phot of yourself you wish to have on your door at LP
*
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