2018 C5LA Student Application Form
Email address *
Student Name *
Student Email Address *
Gender *
Birth Date *
Current School *
Primary language(s) spoken at home *
Ethnicity *
List the names of the adult(s) with whom you live with and their relation *
Number of siblings living in the household *
Home Address *
City *
Zip Code *
Home Phone *
Parent/Guardian Cell Phone Numbers *
Parent/Guardian Email Addresses *
Are you in foster care? *
Type of housing the student lives in *
Occupations of adults living in the home *
Highest level of education of adults living in the home *
Number of siblings who are attending or who have attended college *
C5LA is extended to youth from families that lack resources for quality enrichment experiences like those offered by C5. Income and other financial considerations are a factor in determining eligibility and in the selection of youth. Reporting your family income is required. All information is strictly confidential. What is the total number of people living in the home? *
Total family yearly income *
Do you qualify for free or reduced lunch? *
Why do you want to be a leader? *
What extracurricular activities or organizations are you involved in regularly? *
How do you spend your time after school? *
List 8 words that others might use to describe you: *
Please submit copies of your grades(transcripts) from 6th, 7th, and 8th grade. *
Required
Please submit an essay. The essay topic is: Describe the most difficult experience in your life. What happened? How did you overcome this situation? What did you learn about yourself in the process? How have you grown from it? *
Required
Please submit 1 - 3 letters of recommendation from people who know you well and can describe why you are a good candidate for a leadership program. Coaches, teachers, mentors, pastors, and youth leaders are good choices. Recommendations may NOT come from friends, family members or the person who nominated you.
STUDENT COMMITMENT In signing this document, I am expressing my interest in being part of The C5 Youth Foundation. I understand that The C5 Youth Foundation is a 5 year leadership development program and I am interested in being a leader in my community. If I am selected, I am committing to the program for 5 years. I am prepared to attend up to 4 weeks of camp each summer and 6 - 8 Pathway events during the school year. I understand that I am expected to perform 30-60 hours of service in my community each year, and maintain a minimum B-/C= grade average (2.5). Please initial and date below: *
PARENT/GUARDIAN COMMITMENT If this young person is selected, I agree to attend 1-3 parent meetings each year. I understand that I share responsibility for getting this student to 6-8 events during the school year. I also understand that the C5 Youth Foundation requires youth to perform 30 - 60 hours of community service each year and to maintain at least a 2.5 grade point average to return to camp each summer. Please initial and date below: *
PARENT/GUARDIAN COMMITMENT I understand that the C5 Youth Foundation provides a 5 year leadership development program that includes 4 summer experiences and 6 - 8 required events throughout the school year. I support this student's application to C5 Youth Foundation. Please initial and date below: *
PARENT/GUARDIAN COMMITMENT I approve of this student's participation in the C5 Youth Foundation individual and group interviews. Please initial and date below: *
PARENT/GUARDIAN COMMITMENT I give my consent to the C5 Youth Foundation to take my son/daughter's picture for identification purposes during the C5 program application process. Please initial and date below: *
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