Blue Ridge Energy Leadership Track Application

Blue Ridge Energy Leadership Track Application
How did you hear about Leadership Track
If a friend referred you, please enter their name (they get points).
Student Information

**Please avoid non-alphanumeric characters (*,&,#," etc.)**
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email (personal emails preferred)
example@example.com
Gender
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
County of Residence
Student Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Student Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
High School attending
Graduation Year
T-shirt Size

Family Information
Parent/Guardian Name

First NameLast Name
Parent/Guardian Phone
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Email
example@example.com
2nd Parent/Guardian Name

First NameLast Name
2nd Parent/Guardian Phone
Please enter a valid phone number.Format: (000) 000-0000.
2nd Parent/Guardian Email
example@example.com

Application Requirements

Please answer the following questions:
Briefly describe any leadership skills you already have and the leadership skills you would like to gain or improve upon.

0/2500
Do you feel prepared for the college selection, application and scholarship process? Briefly describe any worries you have.

0/2500
Please list any leadership camps or programs you have attended in the past.

0/2500

Agree and Complete Application
I, do hereby give my consent to Blue Ridge Energy, North Carolina, to use my photograph and comments for promotional purposes in its communications including print, digital, website, video, and other electronic mediums and communications purposes not listed above. I understand Blue Ridge Energy will use the photos and comments for promotional purposes only. Blue Ridge Energy may also send promotional messages to the phone numbers listed above. I understand any standard phone, messaging and/or data charges incurred from my carrier for any alerts I receive are my responsibility.
Please upload a recent headshot (png or jpeg):

Cancelof
Student Signature
Parent/Guardian Signature
Should be Empty: