Youth Leadership Academy — West Georgia Star

Resident Intake Form

Name

First Name

Last Name

Name You Would Like To Be Called (No Nicknames)

Date of Birth

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email address

Phone Number

(###)

###

####

High School

Grade

T shirt size

List any social media accounts you use

Source of Monthly Income

Please list any documented and diagnosed disabilities

Primary Parent/Guardian

First Name

Last Name

Parent/Guardian Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian Phone Number

(###)

###

####

Parent/Guardian Cell Number

(###)

###

####

Parent/Guardian E mail

Secondary Parent/Guardian

First Name

Last Name

Secondary Parent/Guardian Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Secondary Parent/Guardian Phone Number

(###)

###

####

Secondary Parent/Guardian Cell Number

(###)

###

####

Secondary Parent/Guardian E mail

The remainder of the Student’s Application is to be filled out by the applicant him/herself. Parents must not fill out this section of the application for the applicant.

How did you hear about the leadership program?

What are some things you do well?

What are some things you would like to improve about yourself?

Do you have any extra curricular activites that you participate in at school? (if so, list all)

Are you willing to control your temper and language at all West Georgia Star events?

What are some service projects you have been involved in recently?

What are some of your hobbies or special interests?

Are you willing to be in the Youth Leadership Program if none of your friends get accepted?

What is the hardest thing that you have done during the past year?

If your application were accepted how would you personally try to gain the most out of the program and apply it to your everyday life?

You have to attend 3 weekday afternoon sessions and occasional weekend sessions, (depending on need) for the Youth Leadership Program. At this time do you have any scheduling conflicts? If so, please list them below:

Write a paragraph about why you want to participate with Youth Leadership this year and what you hope to get out of the experience:

The following forms must be reviewed and signed (by applicant and parent/guardian) to participate with West Georgia Star and their programs. This document is a summary. More information will be provided in meetings. It is the applicant/participant’s responsibility to ask questions and clarify understanding

I have read and agree to the following documents:

Please go to westgeorgiastar.org/forms to read and download signature forms

Summary of Understanding

Code of Conduct

Media Release

Resident Intake Form

CLICK HERE TO DOWNLOAD FORMS: WESTGEORGIASTAR.ORG/All-FORMS