Student Leadership Program Application

STUDENT LEADERSHIP PROGRAM APPLICATION

The Student Leadership Program seeks motivated students prepared to assume responsibilities that require reliability, ethical conduct, and collaboration. Complete all sections fully and sign the certification at the end. Incomplete applications may be disqualified.

Applicant Information

Date of Birth:    Student ID:    Current Grade/Program:

Contact Information

Parent / Guardian (required if applicant is under 18)

I certify that I am 18 years of age or older:

Academic & Leadership Information

Select leadership roles previously held (check all that apply):

Student Council    Club Officer    Team Captain    Peer Mentor    Community Service Organizer    Other:

References (Provide two)

Personal Statement

Availability

I am regularly available for program meetings and events on:

Emergency & Medical Information

Agreements, Releases, and Acknowledgments

Code of Conduct: As a participant I will demonstrate honesty, respect, and responsibility. I understand that violations of program policies, misconduct, or failure to meet participation requirements may result in disciplinary action up to and including removal from the program. I agree to comply with all rules established by program administrators.

Emergency Treatment Authorization and Liability Release: In the event of a medical emergency, I authorize program representatives to obtain necessary medical treatment for the applicant. To the fullest extent permitted by law, I release, hold harmless, and covenant not to sue the program or its representatives for actions taken in good faith to secure emergency medical care.

Background and Records: I understand that certain leadership responsibilities may require background checks or verification of records. By signing below I consent to any required background or records checks and authorize relevant institutions to provide requested information to program administrators for the purpose of determining eligibility.

Media Release: I grant permission for photographs, video, and quotations of the applicant to be used by the program for educational, promotional, or archival purposes. I understand that images will be used at the discretion of program administrators and may appear in program materials.

Data Use and Confidentiality: Information provided on this application will be used solely for program administration, selection, and safety. Confidential information will only be disclosed to staff, volunteers, and service providers on a need-to-know basis or as required by law.

Certification: By signing below I certify that the information in this application is true and complete to the best of my knowledge. I acknowledge that any material misstatement or omission may result in disqualification or removal from the program. I agree to abide by the program terms and policies described above.

Applicant acknowledges and agrees: I have read and agree to the conditions, releases, and certifications stated in this application.

Additional Information / Notes

Sign Now