Vision 2025 Leadership Institute Application Form Checklist:

This checklist shows you what you will need before you complete your application, so make sure to print out and keep this page. Documentation: Copy of a head shot

Copy of high school transcript Copy of ACT scores, if applicable One letter of recommendation (from school counselor, principal, or teacher)

One letter of service hours verified (optional) Personal Information: Full Name Date of Birth Address Phone Number Email Address Current High School Attending Grade Level Additional Information: Organizations, groups, affiliations, clubs, after-school, sports, and other outside activities you are in Leadership roles you have at school or any organization Different organizations you volunteer with Essay: Include a one page essay that explains 1) what your greatest strengths and weaknesses are, 2) what you want to gain from the program, and 3) why you feel you should be selected.

Date of Enrollment: __________________ID # (Office use only)_____________________________________

*Last Name: ________________________ First Name:____________________________________ MI:______________

*DOB:______________ AGE: ______________ Email Address:______________________________

*Address 1: ________________________________________________________________________________________

*City: _________________________________________________ State: ___________ Zip: _______________________

Address 2: _______________________________________________ *Phone: _________________________

PLEASE CIRCLE:

Race (optional) : CAUC AFRI-AMER ASIAN HISPANIC NATIVE AMER OTHER ___________________

Lives with: Both Parents Mother Only Father Only Mom / Step Dad / Step Grandparent

Relative:_________________________________________ Other:___________________________________________

Parent/Guardian Information

*Last Name: __________________________________ First Name: __________________________ MI: ___________

Spouse Last Name: ____________________________________ First Name:___________________________________

*Home Phone: _______________________ * Work Phone: __________________ Cell Phone: _____________________

Place of Employment: ________________________________________________________________________________

Email Address:_______________________________________________________

PLEASE CIRCLE:

Marital Status: Married Single Divorced Widow/er Separated Other:

Number in Household: _________

School Information Grade: ________(10th—12th)

*School: ____________________________________________________________________________________

School District: LRSD PCSSD NLRSD Private Home School Other

Vision 2025 Leadership Institute Application Form

Organizations, Clubs, After-School Program, Activities, Church Groups or Sport Teams you are in:_______________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

List any leadership positions you have had through any organizations or clubs:______________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

List all charitable groups, clubs and non-profit organizations you have and currently volunteer with, and the date in which

you volunteered with them: ______________________________________________________________________________

_____________________________________________________________________________________________________

______________________________________________________________________________________________________

ALL APPLICANTS –

Please read the following statements before signing below:

I hereby certify that my application contains no false information and is complete, truthful, and accurate to the best of my ability.

I understand that applications for this program, sponsored by Pulaski County Youth Services, are accepted without regards to sex, race, color, national origin, physical/mental disability, religion, or political affiliation.

Therefore stated will be applicable to Title VII of the Civil Rights ACT of 1964, as amended, Title VI of the Civil Rights Act of 1964, as amended and Section 504 of the Rehabilitation Act of 1973, as amended.

I understand that Pulaski County Youth Services may wish to take photographs of students engaged in the program for future promotion.

I release Pulaski County from all liability that may occur in the event of injuries, accidents, or death that may arise while my child is participating in the program.

I give consent for Pulaski County to collect information that may be used for evaluation and/or reporting purposes. I understand that all information enclosed in this application will remain confidential. I authorize any emergency medical treatment for my child should it be deemed necessary.

______________________________ ______________________ Signature of Parent/Guardian Date RECEIPT OF PRIVACY CERTIFICATE My signature below indicates that I have reviewed and received the Pulaski County Youth Services Privacy Certificate and I understand that my personal information will not be used or revealed, except as authorized in 28 CFR Part 22, Section 22.21 and 22.22. I agree to all procedures indicated to protect the privacy and confidentiality of my personal identifiable information. _____________________________________________ ________________________________________ Printed Name Date Parent/Guardian Signature Date _____________________________________________

Signature Date

201 S. Broadway, Suite 220, Little Rock, AR 72201 Office: (501) 340-8250 Fax: (501) 340-8259