Dick Miller Youth Leadership Program Application
***Applications are due by 8:00 pm on Wednesday, September 2, 2026, to be considered for the program.*** Please note: for the 2026-2027 school year, only six (6) juniors will be accepted into the two-year program. There is a $25 registration fee for the course, due after acceptance.
Full Name
*
First Name
Middle Name
Last Name
Name you prefer to be called
Email Address
*
**Most communication for the program is conducted via email. Participants will need to regularly check the email provided.
Cell Phone Number
*
Format: (000) 000-0000.
Class
*
Junior
Senior
School You Attend
*
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Email Address
*
example@example.com
Allergies or Medical Conditions
*
T-Shirt Size
*
Please Select
S
M
L
XL
XXL
Why do you want to join the Dick Miller Youth Leadership Program, and what is one strength you would bring to the group?
*
Please list in order of importance to you up to five activities you have participated in during the last four years (school, volunteer, religious, social, athletic, or other). List the organization/activity; grade in school; and how you were involved.
*
Video Submission
*
Browse Files
Drag and drop files here
Choose a file
Please follow the instructions included in the above graphic. Video submissions longer than two minutes or that do not meet the listed requirements will not be considered.
Cancel
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I verify that I have reviewed the program dates and requirements, and I commit to attending and actively participating in the sessions. I understand that I may miss no more than one session to continue in the program.
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Submit Application
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