Date: ____________
Personal Information
Name: __________________________________________ Date of Birth: ______________
Address: ___________________________________________________________________
Home Number: _______________________ Cell Number:___________________________
Email Address: _____________________________________________________________
School: __________________________________________________ Grade: __________
Please indicate other programs that you have participated in or currently attending.
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Why are you interested in this program? What do you hope to gain from it?
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Describe an individual whose leadership style or skills you admire. How have you been
influenced by this person?
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How do you spend your time outside of school studies?
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What is the most important thing you would like to share about yourself?
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Applicant’s Signature:
Date:
PARENT/GUARDIAN APPROVAL REQUIRED:
I give my permission for my child, ________________________________________, to
participate in L.E.A.P Youth Program. Please fax completed applications to (877) 471-5353,
email applications to [email protected], or mail applications to Take Flight P.O
BOX 3223 Silver Spring, MD 20918. For additional information, contact Paul Williams at (240)
839-1848.
Parent/Guardian Signature:
Date: