***Please print or type clearly***
1. Student Name: ___________________________________________________________
(First) (Middle) (Last)
2. Mailing Address: ____________________________________________________
3. Email: ________________________________@___________________________
4. Phone Number: (____)____________ Alt. Phone Number: (____)______________
5. Best method of contact (circle one): Mail Phone Call Text Email
6. Gender: ______ Race: _______ Date of Birth: ___________ Shirt Size: _____
7. High School Name: ___________________________ Current GPA: ________
8. 2009-2010 School Year Classification: Freshman Sophomore Junior Senior
9. SPU Group Name: ___________________________________________________
10. Have you served as a group or regional SPU Officer? If so, please explain.
________________________________________________________________________
________________________________________________________________________
11. Parent/Guardian Name(s): ____________________________________________
12. Parent Phone: (____)_______________ E-mail:_____________@___________
13. Parent Address: ____________________________________________________
14. Best method of contact (circle one): Mail Phone Call Text Email
14. Please list two adults that would provide a character reference for you. These could be community leaders, church members, or teachers/counselors.
Name Association Phone Number Alt. Phone Number
_____________________________________________________________________________________________
______________________________________________________________________________________________
Please list your top three (3) career goals:
1. _______________________________________________
2. _______________________________________________
3. _______________________________________________
If we asked your best friend to describe you, what 3 adjectives would she/he use?
1. ______________________________________________
2. ______________________________________________
3. ______________________________________________
List your significant SCHOOL achievements/awards/accomplishments of the past 2 years. You may also include any club, organization, or sport you are involved in.
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
List your significant NON-SCHOOL achievements/awards/honors of the past 2 years that demonstrate
your level of commitment to a task or program.
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
_______________________________________________________________________________________
Please write in your own words why you are interested in the Special Prevention Unit, specifically the Youth Leadership Training Retreat. What do you feel you can offer your Special Prevention Unit group and community? Feel free to use specific examples from your life experiences.
_____________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
As you are considered for selection for the SPU Youth Leadership Training Retreat, what is the ONE most
important thing that the selection team should remember about you?
________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
ACCEPTANCE CRITERIA
________ I have read and understand the SPU Youth Leadership Training Retreat program description.
________ I understand if I am accepted into the program, I must be able to attend the program the week of August 4-7, 2009.
________ I understand that I (or my parent) am/are responsible for providing transportation to the regional bus stop on August 4-7, 2009.
________ I will abide by the guidelines set forth by the Program Director and Chaperone.
Signed: __________________________________ Date: ____________
Student
PERMISSION STATEMENT
I hereby grant permission for my son/daughter to apply to this program. I understand that if my son/daughter is accepted, we will be responsible for his/her transportation to and from the regional bus stops. I also give my permission for photos taken at the annual training to be used for future promotion.
Signed: __________________________________ Date: ____________
Parent/Guardian