Class of 2019 Application
To apply for membership please complete all questions
Full Name
*
First Name
Last Name
School
*
2018-2019 School Year
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Sophomore
Junior
Senior
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
Cell Phone
*
-
Area Code
Phone Number
Home Phone
*
-
Area Code
Phone Number
E-mail
*
What are three things you are concerned about in our community?
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Why do you feel you will benefit from Youth Leadership Pinellas?
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What will you contribute to Youth Leadership Pinellas?
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Over the past 2 years what activities have you been involved in that were important to you (school, volunteering, sports, job, etc.)?
*
What are your hobbies/interests?
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Will any activities interfere with your participation in Youth Leadership Pinellas? If yes, which ones?
*
References
Statements from two (2) references should be submitted in addition to this application. Print the form below and return to Jennifer McGrail, Executive Director, at contact@leadershippinellas.com or Leadership Pinellas, PO Box 5986, Clearwater, FL 33758. The deadline for references is April 6, 2018.
Tuition for Youth Leadership Pinellas is $400 and is due in full by the September Parent Meeting. Financial Assistance is available. If you would like to be considered for assistance, please check that you qualify for free/reduced lunch program.
Financial Assistance Request
Applicant Personal Commitment
I understand the purpose of Youth Leadership Pinellas and, if I am selected, I will devote the time necessary to complete the program and I will abide by the Principles of Participation.
Principles of Participation
At least one parent/guardian is required to attend the Parent Meeting in September. Parents/Guardians are responsible for transportation to and from the bus on YLP Program Days. All program days (with the exception of the Opening Retreat) begin and 7:30 a.m. and end at 4:30 p.m. If the bus is scheduled to be back a few minutes before or after 4:30 p.m., students and parents will be notified in advance. Students are expected to participate in the full program day. They may not be picked up early during the day unless for an emergency. The YLP Chair must be advised in advance if the student is to be picked up by someone other than the parent/guardian.
Signature
*
Signature Date
*
Parental Permission
I am the parent/legal guardian of the student listed above. I have read the information and participation guidelines and am will to have my child participate if selected. Youth Leadership Pinellas, its agents and its employees have my full permission and consent to transport and otherwise provide transportation for my child by public service bus, private chartered bus, private automobile, or other means of transportation in connection with all sessions of Youth Leadership Pinellas during the school year in which he/she is a participant. Further, I understand that Youth Leadership Pinellas is a program run separate from any public or private school related program. The student is responsible for making up missed work and for getting the absences excused through school for all program days my child is away from school. I hereby release and hold harmless Youth Leadership Pinellas, Leadership Pinellas, its members, agents, employees or any individuals involved in the planning, organization or presentation of Youth Leadership Pinellas programming, for any accident, injury, illness or any damage whatsoever related to the above mentioned student's attendance at or participation in any activities or session of Youth Leadership Pinellas.
Parent Signature
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Parent/Legal Guardian Name
*
First Name
Last Name
Parent/Legal Guardian Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent Email
*
example@example.com
Parent Phone
*
-
Area Code
Phone Number
All applications must be submitted by 5:00 p.m. Friday, April 6, 2018.
Submit Form
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