Leadership Empowerment & Academic Development (LEAD) Mentor Question Title * 1. Contact Information: First Name: * Last Name: * Address: * Address 2: City/Town: * State: * -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: * Email Address: * Phone Number: * Question Title * 2. Sex: Male Female Question Title * 3. Age: Question Title * 4. Birth Date: Month Day Year Birth Date January February March April May June July August September October November December Birth Date Month menu 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Birth Date Day menu 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 Birth Date Year menu Question Title * 5. Select a Location: Los Angeles, CA: June 11-14 Dallas, TX: July 9-12 Albuquerque, NM: July 16-19 Silicon Valley, CA: August 6-9 Washington, DC July 30-August 2 Question Title * 6. Currently, I am a: College Junior College Senior Graduate Student Young Professional Question Title * 7. Please provide your graduation/expected graduation date: Month Day Year Date January February March April May June July August September October November December Date Month menu 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Date Day menu 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 Date Year menu Question Title * 8. School Name: Question Title * 9. Your Major: Question Title * 10. Have you been awarded a scholarship from HSF? Yes No Question Title * 11. If yes, in what year were you awarded an HSF scholarship? Question Title * 12. Are you a Gates Millennium (GMS) Scholar? Yes No Question Title * 13. If yes, in what year were you awarded the GMS Scholarship? Question Title * 14. Have you previously participated in the Youth Leadership Institute (formerly HYI/HYS)? Yes No Question Title * 15. If yes, in what role did you participate? Fellow Alumni Team Member LEAD (formerly Resident Advistor) Jr. LEAD (formerly Junior Resident Advistor) High School Participant Question Title * 16. What three skills and/or abilities would you bring to this position? 1. 2. 3. Question Title * 17. Why would you be a good LEAD Mentor for the Youth Leadership Institute? (250 min-300 max words) Question Title * 18. List your extra-curricular activities: 1. 2. 3. 4. 5. Done