Youth Leadership Camp
Student Registration  

Please complete registration form in its entirety.
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Youth Leadership Camp
Student's First Name *
Student's Last Name *
School Attend *
Student's Date of Birth *
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Grade Level
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Expected graduation year?
Preferred Language
 *
Student's Gender
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Student's Race
 *
Student's Ethnicity
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Describe any past leadership roles you have held (e.g., school clubs, sports teams, community organizations).
List any leadership training or workshops you have participated in.
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Describe your involvement in any community service activities or volunteer organizations.
How do you currently contribute to your community?
Why are you interested in the Youth Leadership Camp?

What do you hope to learn and achieve by participating in this program?

How do you envision using your leadership skills to make a positive impact in your community?

Parent / Guardian Last Name *
Parent's / Guardian's Phone *
Parent / Guardian Email *
Does your child have a learning disability?
 *
Does your child have any food allergies? If so, please explain below.
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Home Street Address (Example: 1234 Main Street) *
City *
State *
Zip Code *
Household size
Including yourself, how many people currently live in your household?
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Annual Household Income
Please count income from all members of your household, and from all sources.
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Program Agreement:

I have read and understood the Youth Leadership Program Guidelines.

I agree to abide by all program rules and regulations.

I understand that I am responsible for my own transportation to and from all program sessions.

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To promote, evaluate or otherwise describe the training and education programs and activities of the To You From Us organization, I give permission to the To You From Us organization and its agents to use any publications (including brochures, videos, reports, press releases, websites and exhibits, among other methods) any image or recording in which my child, a minor, appears. I also give permission to use and quote any comment(s), verbal or written, made by or said by the minor about the program, and to use the minor's first name in connection with any posting in the manner determined by To You From Us.

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