Panhandle Youth Access & Prevention Leadership Academy Application 🎓✨
Apply to join a free leadership academy for high school students, and help shape community prevention efforts.
Student Information
Full Name
*
First Name
Last Name
Preferred Name
Date of Birth
*
 -
Month
 -
Day
Year
Date
Grade Level
*
Please Select
9th
10th
11th
12th
School Name
*
Contact Information
Student Email
*
example@example.com
Student Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Information
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Email
*
example@example.com
Parent/Guardian Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Interest & Leadership
Why is the student interested in joining this academy?
*
What substance use or impaired driving issues do teens face?
*
Describe any leadership, school, youth council, volunteer, or community activities the student has participated in.
Commitment & Logistics
Can you attend the full day on Thursday June 25, 2026?
*
Yes
No
Are you interested in serving as a Youth Advisor after the academy?
*
Yes
No
Permissions
Internal Reviewer Guidance
For internal review only
Scoring rubric (100 points): Interest in prevention/community impact — 25; Understanding of youth substance access or impaired driving concerns — 25; Leadership potential and willingness to participate — 20; Availability/commitment to attend full day and possible youth advisor role — 15; School/community representation and overall fit — 10; Need for transportation/support considerations — 5.
Suggested decision categories: Accepted = 80–100; Waitlist = 65–79; Not selected at this time = below 65 or incomplete/unavailable.
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