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Name:
(last) (first)
(middle) |
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Name I wish to go by/ want on my nametag: |
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Address: |
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Home Phone: Cell Phone:
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Date of Birth: Email Address:
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School:
Grade: |
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In what activities do you participate and what role do you play - inside and outside of school? |
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Do you feel that you can benefit from Youth Leadership Pinellas? Why? |
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What can you contribute to a community leadership program? |
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Using a few phrases or adjectives, please describe yourself: |
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What three things are you concerned about in our community? |
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What are the four activities (school, volunteering, church, athletics, etc) most important to you, in
which you have been involved over the past four years? |
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Do you currently have a job? If so, briefly describe your duties. |
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Would your work interfere with your participation in Youth Leadership Pinellas?
Yes
No |
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What else would you like to tell us about yourself? |
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Whom do you most admire? |
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What qualities do you most admire in others? |
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What are your hobbies? |
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In 200 words or less, please respond to:
If you could change anything in your community, what would it be? Why and how would you do it? |
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References: Statements from references should be furnished from those you list below and given
directly to the YMCA of the Suncoast. Reference forms are provided. |
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Name of reference |
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Mailing address: |
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Daytime phone: Relationship:
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Name of reference |
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Mailing address: |
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Daytime phone: Relationship:
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100% attendance is expected and required for graduation from Youth Leadership Pinellas.
If selected, I commit to full participation in all sessions and to established standards of the
program.
Applicant signature:
______________________________________________________________
Parent/Legal guardian signature:
__________________________________________________ |
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Youth
Leadership Pinellas
Please remit to:
Shannon L. Kimball,
Executive Director
YMCA of the Suncoast, North Pinellas YMCA
4550 Village Center Dr
Palm Harbor FL 34685
Phone: (727) 772-9622 |