Jennings County Youth Leadership (JCYL) Application

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* 1. Student's Contact Information

Name

Address

City/Town

State

ZIP Code

Student's Email

Student's Cell Phone

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* 2. Do you get texts?

No

yes

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* 3. Wireless Carrier (Ex: Verizon, ATT, etc)

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* 4. 2018-19 Grade (next year)

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* 5. I am an 8th grader referred by: (Must be a school representative)

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* 6. Shirt Size:

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* 7. Parent's Contact Information

Name(s)

Email Address

Best Phone Number

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* 8. I would like to be involved in Jennings County Youth Leadership because...

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* 9. What do you expect to gain by being involved in Jennings County Youth Leadership?

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* 10. What do you think is the biggest problem facing youth?

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* 11. Have you ever attended any type of Leadership Training? If so, please explain.

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* 12. Please list your extracurricular activities.

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* 13. What are your future plans?

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* 14. What does “Community” mean to you?

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* 15. Participation in JCYL involves missing class one day a month and you must communicate with your parents, teachers, and make up assigned work. Other time commitments may include leaving before school starts, one trip returns around 6:30PM, occasional evening and weekend or summertime projects. How does this affect your schedule or other activities?

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* 16. JCYL will provide monthly learning experiences, activities and trips off campus- you will miss class and be required to make up missed work & assignments. Are you willing to make this commitment to the JCYL Program?

No

yes