Golden LEAF Scholars Leadership Program -- Year 4 Application
Year 4 of the Golden LEAF Scholars Leadership Program is open to all continuing scholars who completed Year 3 of the GLSLP. This application confirms your interest in continuing with the program and will be used as your registration to join us at the mandatory kick-off leadership conference in Greensboro, NC from January 18=20, 2019.

The Golden LEAF Foundation is a 501(c)3 nonprofit devoted to improving the economies of tobacco-dependent, economically distressed and/or rural North Carolina communities. The GLSLP is a grant-funded partnership between the foundation and the Center for Creative Leadership.

Your Demographic & Contact Information
First Name *
Your answer
Last Name *
Your answer
Middle Initial
Your answer
School Email Address *
(This is the default email we will be using for future correspondence)
Your answer
Personal Email Address *
Your answer
Cell Phone *
(000)-000-0000
Your answer
Home Phone (if applicable)
(000)-000-0000
Your answer
What year were you born? *
Your answer
Gender Identity *
Race/Ethnicity *
Required
Your Permanent Mailing Address (use the same one for all forms)
Street *
(Please do not list PO Boxes or School Addresses)
Your answer
City *
Your answer
Zip Code *
Your answer
Home County *
Your answer
Your College/University Information
Name of College/University *
Your answer
Major *
Your answer
Your Parent/Guardian & Emergency Contact Information
Parent/Guardian Name *
Your answer
Parent/Guardian Cell Phone Number *
(000)-000-0000
Your answer
Parent/Guardian Home Phone Number *
(000)-000-0000
Your answer
Parent/Guardian Email Address *
Your answer
Emergency Contact Name *
Your answer
Emergency Contact Phone Number *
(000)-000-0000
Your answer
Relationship to Emergency Contact *
Please list your relationship to your emergency contact (parent, sister, spouse, partner, etc.)
Your answer
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