YES Leadership Student Application

Student Information

First Name

Last Name

Age

Birthday

Current Grade

School

Student Identity

Current Gender Identity

Are you a U.S. citizen?

If no, what is your citizenship status?

Are you of Hispanic, Latino, or Spanish origin?

Which race do you identify with? Select all that apply. You may select more than one group

What language do you primarily speak at home?

Do you have a disability or special needs?

If yes, please specify the disability:

Student contact Info

Street Address

City

Zip Code

Cell Phone

Academics Information

Current GPA

Counselor's Name

Current Class List

Optional - upload a copy of your current schedule

Referrer's Name

Referrer's Position/Title

About You

What do you see as your path following high school?

For any option, what is your primary area of interest?

If you are interested in joining the military, which branch do you see yourself joining?

Statement of Interest: Please provide a statement outlining your aspirations following high school. What do you perceive as obstacles that may prevent you from achieving your goals? Who are the people in your life that give you strength and encouragement? What resources from your community will help you to realize your dreams?

Community Service: Tell us more about how you are currently serving / participating in your community.

Extracurriculars: Tell us more about what you like to do for fun!

Optional: Upload your transcript

Parent/Guardian Info

First Name

Last Name

Relationship to student

Cell Phone

Work Phone

Emergency Contact

You will be our primary point of contact in the case of an emergency. Please include an additional emergency contact.

First Name

Last Name

Cell Phone

Parent/Guardian Identity

Are you a U.S. citizen?

If no, what is your citizenship status?

Are you of Hispanic, Latino, or Spanish origin?

Which race do you identify with? Select all that apply. You may select more than one group

Do you have a disability or special needs?

If yes, please specify the type of disability.

Household Information

How many people are currently living in your household?

How many adults (18 years and older) are in your household?

How many children (under 18 years) are in your household?

What type of housing does your household occupy? (e.g., single-family home, apartment, condominium)

How many people currently living in your household are employed?

Please list the occupation of each employed member in your household.

What is your total annual household income?

How would you describe the primary racial or ethnic background of your household members? (Select all that apply)

Are there any veterans living in your household?

Are there any members of your household with disabilities or special needs?

If yes, please specify the type of disability.

Does your household have access to a vehicle?

Does your household have access to the internet?

By submitting this application, I affirm that the facts outlined in it are accurate and complete. I consent to participate in this application and provide the above information voluntarily. I understand that submitting this application does not guarantee my acceptance into the Reaching Out Now Leadership program and participation in the program is voluntary.