If you chose "other" please list amount you can afford.

First Name *

Last Name *

Preferred name (i.e. Bob for Robert)

Date of Birth *

I identify my gender as *

Enter required value Female Male Non-binary Other

Race/Ethnicity *

American Indian/Alaska Native

Arab/Middle Eastern/North African

Asian or Asian American

Black/African American

Hispanic/Latino

Native Hawaiian/Pacific Islander

White/Caucasian

Multiracial

Other

How did you hear about the Youth Summer Leadership Program?

I have a sibling/relative that participated in Youth Leadership Academy. *

Enter required value Yes No

Home Address *

City *

State *

Enter required value

Postal Code *

Best number to reach you at: *

Email you check frequently: *

Alternate email (not issued by school, i.e. gmail, if different than above)

School (if you attend a campus please specify "small school" name): *

Expected High School Graduation *

Enter required value Class of 2023 Class of 2024 Class of 2025 Class of 2026

First Name (Parent/Guardian) *

First Parent/Guardian First Name *

First Parent/Guardian Last Name *

First Parent/Guardian Mailing Address *

First Parent/Guardian City, State, Zipcode *

Relationship to the applicant? *

Phone Number *

Email *

Second Parent/Guardian Name

Second Parent/Guardian Mailing Address

Second Parent/Guardian City, State, Zipcode

Relationship to the applicant?

Phone

Email

Tuition *

Tuition for the program is $300. There are a limited number of scholarships available. Please indicate if you need a scholarship, and the amount you are requesting.

If you do not need a scholarship, please enter N/A.