Midland Young Leaders Challenge with General Tommy Franks - Application
Please complete the following information.
Email address *
Student Details
Please complete the following information about yourself.
Student's First Name *
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Student's Last Name *
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Student's School *
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Current Grade Level *
Student's Email *
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Phone Number *
Your answer
Street Address *
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City *
State *
Zip Code *
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Date of Birth *
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Current Grade Point Average (GPA) *
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Gender *
How did you learn about the program? *
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Parent/Guardian Details
Please complete the following information.
Parent/Guardian First Name *
Your answer
Parent/Guardian Last Name *
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Parent/Guardian Phone Number *
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Parent/Guardian Email *
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Parent/Guardian Street Address *
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Parent/Guardian City *
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Parent/Guardian Zipcode *
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Emergency Contact Name *
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Emergency Contact Phone Number *
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Student Experience
List organizations you are a member of and your leadership role in them *
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Leadership experience and impact *
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Share an example of how you lead through service. *
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Describe your leadership experience and impact. *
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Reference Details
Please notify your reference person of your application. Your reference will receive an e-mail to fill-out a form requesting more information concerning your leadership activities and character. You application will not be complete without your reference’s form.
Reference First Name *
Your answer
Reference Last Name *
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Reference Title *
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Reference Relationship to Student *
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Reference Email *
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Reference Phone Number *
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Electronic Signature
By entering your names and submitting this application, you agree to the terms below.
Agreement Information
I hereby agree that all information on this form and attached forms is true and correct to the best of my knowledge and give permission for my child to attend the Midland Young Leaders Challenge with General Tommy Franks at Midland College on June 13th and 14th, 2018.

AUTHORIZATION TO UTILIZE PHYSICAL LIKENESS, NON-UNION PRODUCTION:
I expressly grant to Midland College, Midland Independent School District, and the General Tommy Franks Leadership Institute and Museum and to their employees, agents and assigns, the right to photograph and videotape me and use my picture, silhouette and other reproductions of my physical likeness (as the same may appear in any still camera photograph and/or videotape) in and in connection with the exhibition on television, the internet, cassette, DVD or otherwise, of all the television shows, conventions, “clips” promos, magazine, newspaper articles, etc. in which my participation is included and in which the same may be used or incorporated and utilized throughout the world, and also in the advertising, utilizing and/or publicizing of any such image, but not limited to television. These groups shall have the ability to edit the program/video as it so requires. I further give these groups the right to reproduce in any manner whatsoever any recordation made by said company of my voice and all instrumental, musical, or other sound effects produced by me.

Student's Full Name *
Your answer
Parent's Full Name *
Your answer
If you are selected to participate in the Midland Young Leaders Challenge with General Tommy Franks you will be notified by May 1, 2019.
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