Apply to Youth Leadership Jackson (YLJ)

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School Name*
Other Schools Attended
School Name Year(s) Attended
Special Awards, Honors or Recognitions
List up to three special awards, honors, or recognition for academic, school or community-related activities you have received from the 7th to 10th grades.
What is your main area of interest in studies?

Organizations and Activities
Please List in order of importance to you up to five school, volunteer, religious, social, athletic or other activities or organizations in which you have participated during the past four years.
Organization/Activity Grade in School Leadership Responsibility/Involvement

Work Experience
List any part-time job experience, paid or volunteer, and briefly tell what it involved.
Employer From To
Do you currently have a part-time job?
- YES
- NO
How many hours per week?
Would your job interfere with your attendance at You th Leadership Jackson?
- YES
- NO

If you could change anything in your community, what would it be and how?*
Please respond in 250 words or less.

References
Please give one reference form to your high school principal / headmaster or counselor. Give the second one to any adult who knows you well, other than a parent or relative, for example, a teacher, scout leader, church youth leader, etc. If this is your first year at your current school, give the second reference to a teacher, principal / headmaster or counselor at the school you attended last year.
Position/Title Address Phone Number
Email
This field is for validation purposes and should be left unchanged.

School Name	Year(s) Attended

Organization/Activity	Grade in School	Leadership Responsibility/Involvement

Employer	From	To

Position/Title	Address	Phone Number