S.J. Petteway Leadership and Scholarship Program

S.J. PETTEWAY FAMILY YOUTH LEADERS SCHOLARSHIP INITIATIVE

2025/2026 Program Application
INSTRUCTIONS

Thank you for applying to the S.J. Petteway Family Youth Leaders Scholarship Initiative. The application consists of 4 parts:

1. Contact Information of the student applicant and parent/guardian;

2. Short essay questions to help us to get to know you a little bit better;

3. Email addresses for 2 references; and

4. The signature of the student applicant and parent/guardian.

Each part must be completed to apply. Please note, required fields are indicated with a red asterisk *. If you have any questions, feel free to email us at sclark@leadersinstitutemd.org and we will get back to you within 1 business day.

We look forward to learning all about you!
Student and Parent/Guardian Information
Student Name*

First NameLast Name
Student Birthdate*

MonthDayYear
Student Phone Number*
000-000-0000
Student Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Student Non- School Email*
Name of Student School*
Grade in School Fall 2025*
Have you applied to a college, university or vocational school?*

yesno
What schools or programs have you applied to?*
What field of study are you interested in majoring in?*
(Law, Sports, Entertainment, Business, Social Work, Medicine, Engineering, Computer Science, etc).
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Email*
example@example.org
Parent/Guardian Phone*
000-000-0000
How did you find out about the S.J. Petteway Family Youth Leaders Scholarship Initiative?*

Tell us about yourself

To apply to the S.J. Petteway Family Youth Leaders Scholarship Initiative, please answer the following questions honestly and completely. There are no right or wrong answers to the questions – we’re simply trying to get to know you a little better.
Why did you apply to this program and what do you hope to get out of it?*

0/500
Describe a situation where you led a group or project. What challenges did you face, and how did you overcome them? *

0/500
Tell us about a time when you faced an ethical dilemma. How did you handle it, and what did you learn? *

0/500
How would you define ethics? Give examples of your personal code of ethics. *

0/500
What is the most important lesson you have learned about leadership, and how has it shaped who you are today? *

0/500
There is a quote that reads "Be the change you want to see in the world." (Mahatma Gandhi). What change do you want to see in your local school or community and why? *

0/500
In what ways can you contribute to the change you want to see in your local school or community?*

0/500
Is there anything else you want to tell us about yourself or further explain in your application?

0/500

Recommendations

Please provide the following information for each Recommender: first and last name; email address. Recommenders will receive a form link and deadline notification at the email address provided. You are responsible for notifying your recommender of the request and ensuring completion by the application deadline, Sunday, January 11, 2026 by 10:00 PM.
Teacher Name (Note: This should be a teacher who has taught you in an academic class and should not include an advisor, coach, or extracurricular instructor.) *

First NameLast Name
Teacher Recommendation*
example@example.org
Community Recommender Name (Note: This should be an adult community member who has worked with you in a professional or project setting such as a Sunday School teacher, coach, supervisor of an extracurricular activity, or a client such as someone you have babysat for and should NOT include a family friend or neighbor.)*

First NameLast Name
Community Organization Recommendation*
example@example.org

Signatures
Student Applicant Acknowledgement
By signing below I certify that:
- Every answer given on my application is true and complete to the best of my knowledge.
- I am a student in twelth grade who resides in Waterbury, CT or surrounding area.
- I am familiar with the program requirements and fully understand the expecatations and rigors of the program.
- I have read the application instructions thoroughly.
- I understand that, if accepted, I am expected to participate in every seminar, meeting, and activity.
Student Signature*

Clear
Parent/Guardian Acknowledgement
By signing below I certify that:
- If accepted, my child has permission to participate in all of the activities of the S.J. Petteway Emerging Leaders Scholarship & Development Program.
- I have read the S.J. Petteway Emerging Leaders Scholarship & Development Program materials and fully understand the expectations and rigors of the program.
- I grant permission for my child to appear in person and in voice, or photographic presentation for internet, print, radio or television reports resulting from participation in the program.
- I give permission for my child to be transported by authorized staff, volunteers, or transportation providers of the S.J. Petteway Emerging Leaders Scholarship & Development Program for program activities and events. I acknowledge that transportation may include, but is not limited to, travel by car, van, bus, or other approved vehicles. I understand that advance notice will be given and that reasonable safety measures will be taken. I release S.J. Petteway Emerging Leaders Scholarship & Development Program and its representatives from liability during transportation, provided due care is exercised.
Parent/Guardian Signature*

Clear
Should be Empty:

S.J. PETTEWAY FAMILY YOUTH LEADERS SCHOLARSHIP INITIATIVE

Thank you for applying to the S.J. Petteway Family Youth Leaders Scholarship Initiative. The application consists of 4 parts:

1. Contact Information of the student applicant and parent/guardian;

2. Short essay questions to help us to get to know you a little bit better;

3. Email addresses for 2 references; and

4. The signature of the student applicant and parent/guardian.

Each part must be completed to apply. Please note, required fields are indicated with a red asterisk *. If you have any questions, feel free to email us at sclark@leadersinstitutemd.org and we will get back to you within 1 business day.

We look forward to learning all about you!

Student and Parent/Guardian Information

Tell us about yourself

Recommendations

Signatures