Youth Leadership Application Form

First and Last Name

Date of Birth

School

Grade

Home Address:

City

State and Zip Code

Phone

List the clubs/organizations and other activities in which you are participating:

Can you attend meetings or events after school and on weekends?

Yes

Maybe

Would you have time to dedicate to participating in the program 1 – 2 times per month (meetings or activities)?

Yes

Can you attend the MANDATORY youth leadership skills training?

Yes

If no, please explain:

Why do you want to serve as a youth leader?

What personal STRENGTHS would you bring to the program?

What is your biggest concern related to alcohol, tobacco and other substance issues in the community? How would like to see these issues addressed?

For the days above that you selected, what TIME of day is best for you?

PERSONAL SUBSTANCE USE PHILOSOPHY – Please discuss your own beliefs about alcohol, tobacco and other substance use, misuse and addiction.

RECOMMENDATIONS

At least 2 recommendations are requested for consideration in this program. One recommendation is required from a teacher. Other possible recommendation sources include school staff, employer, co-workers, clergy, etc. Please provide the names and email addresses of references in the spaces below.

First and Last Name

Email Address

First and Last Name

Email Address

First and Last Name

Email Address