2017 ARAB YOUTH SUMMER LEADERSHIP INSTITUTE FOR YOUTH EMPOWERMENT & COMMUNITY ORGANIZING
Presented by: The Arab Resource and Organizing Center (AROC) and Arab Youth Organization (AYO)

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Email address
Personal Information:
First Name
Your answer
Last Name
Your answer
Birthdate
Your answer
Place of Birth
Your answer
Families' Country or Countries of Origin
Your answer
Religious Identity
Your answer
Gender
Your answer
School Grade Level
Indicate what grade you will attend next year, if you are graduated, or if you are not in school
Your answer
School Name and City
Your answer
Languages Spoken
Your answer
What language are you most comfortable communicating in? (written and spoken)
Your answer
What is your approximate family income?
Are you in need of financial assistance for transporation costs from your home to the program locations?
Contact Information:
Street Address
Your answer
City, State
Your answer
Zip Code
Your answer
Home Phone
Your answer
Cell Phone
Your answer
Email Address
Your answer
Emergency Contact Name
Your answer
Emergency Contact Phone
Your answer
Emergency Contact Phone
Your answer
Physician Name (if applicable)
Your answer
Physician Phone (if applicable)
Your answer
Insurance Carrier and Policy Number (if applicable)
Your answer
Medications taken
Your answer
Allergies
Your answer
School and Community Involvement Experience
What kinds of activities are you involved in through your community, school, or elsewhere?
Your answer
Do you experience challenges in your school or community because of your religious or racial background? If yes, how do you manage to face these challenges?
Your answer
What would you like to learn or gain from participating in this institute? (List at least 3 concrete goals)
Your answer
How do you think you could use this experience in the future?
Your answer
How do you think you could use this experience in the future?
Your answer
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Commitment Pledge
Thank you for your application!

Depending on the quantity of applicants, youth may be asked to participate in an interview process in order for the selection committee to make its final decision.

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