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Young Men's Program
Submission Date
*
Date of Birth
Emergency Contact Name
Emergency Contact Phone Number
Relationship to Emergency Contact
Education and Employment
Current School/College (if applicable)
Current Grade Level/Year in School
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Freshman
Junior
Other
Senior
Sophomore
Current Employer (if applicable)
Job Title
Employment Status
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Employed - Full Time
Employed - Part Time
Employed Seasonally
Retired
Student
Unemployed
If not currently employed have you ever held a job before?
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No
Yes
Personal Background and Interests
Tell us a little about yourself and why you are interested in the Young Men's Transformational Leadership program.
Do you have any children?
-
No
Yes
What are your main goals for participating in this program?
List any activities hobbies or interests you are involved in.
What type of careers interest you?
Health and Wellness
Have you ever been diagnosed with a mental illness?
-
No
Yes
If yes please specify:
Do you have any medical conditions, disabilities, or special needs that we should be aware of to ensure your safety and well-being during the program?
-
No
Yes
If yes please provide details.
References
Reference 1: Name
Reference 1: Relationship
Reference 1: Phone Number
Reference 1: Email Address
Additional Information
Do you have any prior criminal convictions? If yes please provide details.
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No
Yes
If yes please provide details.
How did you hear about the Young Men's Transformational Leadership program?
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Friend/Family
Other
School
Social Media
Website
Any additional comments or questions?
Submission Date
Date of Birth
Emergency Contact Name
Emergency Contact Phone Number
Relationship to Emergency Contact
Education and Employment
Current School/College (if applicable)
Current Grade Level/Year in School
Current Employer (if applicable)
Job Title
Employment Status
If not currently employed have you ever held a job before?
Personal Background and Interests
Tell us a little about yourself and why you are interested in the Young Men's Transformational Leadership program.
Do you have any children?
What are your main goals for participating in this program?
List any activities hobbies or interests you are involved in.
What type of careers interest you?
Health and Wellness
Have you ever been diagnosed with a mental illness?
If yes please specify:
Do you have any medical conditions, disabilities, or special needs that we should be aware of to ensure your safety and well-being during the program?
If yes please provide details.
References
Reference 1: Name
Reference 1: Relationship
Reference 1: Phone Number
Reference 1: Email Address
Additional Information
Do you have any prior criminal convictions? If yes please provide details.
If yes please provide details.
How did you hear about the Young Men's Transformational Leadership program?
Any additional comments or questions?
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