Applicant Name
Your Address
Your City Zip Code
Your Home Phone Number
Your Cell Phone Number
Date of Birth (example: 2013-04-08)
Your Age
Your Gender MaleFemale
Your Email
Best way to reach you Home PhoneCell PhoneEmail
Parent/Guardian Name
Parent/Guardian Home Phone Number
Parent/Guardian Cell Phone Number
Parent/Guardian Email
A lot of communication is done via phone and/or e-mail. If your child is accepted, please let us know if any contact information changes
School Name
Grade
School Contact Person/Counselor
School Contact Person/Counselor Email
Name of Hometown Newspaper
T-Shirt Size
I found out about ADAPT through: school counselor/teacher/etc.ADAPT Youth LeaderADAPT Adult Coalition MemberOther:
Other
Name of Person Referring/Endorsing you and Relationship:
Are you available for summer meetings? YesNo
Optional Information: ADAPT does not discriminate based on race, ethnicity, sex, creed, national origin or disability. This information is not required. It is requested to facilitate our goal of assembling a diverse team.
Race/Ethnicity: American IndianAsianAfrican AmericanHispanicWhiteOther: Other:
Please let us know the organizations or activities you are involved in, both in your school and/or community. These should be in order of importance, listing up to five; school, social, athletic, religious, community service, scouting or other activities and organizations in which you have participated during the last two years. If you have held a leadership position in that group- please specify what kind.
List any accomplishments, awards, honors or recognitions for academic, school, religious or community activities you have achieved or received in the last two years.
List any community service or volunteer work experience and briefly tell what was involved.
Why are you applying for ADAPT’s Youth Leadership Team?
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