Recruiting Form - Youth Leadership Program
Completion of this form means you are interested in being contacted for enrollment in the free, after-school Youth Leadership Program. IT DOES NOT MEAN THAT YOU ARE AUTOMATICALLY ENROLLED.

You will be contacted prior to our next enrollment drawing. Any student not selected for enrollment at the time of the drawing will automatically remain on a wait list for the next session.
Free After-School Program for Middle & High School Students
Student Name (first & last) *
Your answer
Grade *
Gender
Student Phone Number (if applicable)
Your answer
Parent Name (first & last)
Your answer
Parent Phone Number
Your answer
Alternative Phone Number (optional)
Your answer
Email address (optional)
Your answer
Best Method of Contact
Availability
The program meets twice-a-week after school for 14 weeks. There is a group that meets on Mondays & Wednesdays (Mon/Wed group) and a group that meets on Tuesdays & Thursdays (Tues/Thurs group). We draw names out of a hat to fill the available spots. Your name can go in either the Mon/Wed hat, the Tues/Thurs hat, or both hats if you are available for either group. Please tell us about your availability to fully participate in this 14 week program.
Availability
Anything Else?
Anything else you'd like us to know before we contact you?
Notes
Your answer
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