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Hancock Youth Leadership
Application
INSTRUCTIONS - Please read all instructions before completing this form.
1.
Make sure you are eligible. Applicant must:
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Attend a high school in Hancock County, or be a resident of Hancock County.
Apply as a sophomore for the program, attend the program your junior year.
Be approved by your principal and/or guidance counselor.
Demonstrate a potential for leadership in school and/or community activities.
Have an interest in addressing the issues confronting your community.
Be academically sound. A minimum 3.0 grade point average is required.
Demonstrates a positive attitude and responsible behavior within the program and at school.
The applicant must commit to full participation and attendance in the program. Absences are closely
monitored by the HYL Board and may result in removal from the program. This program will
require students to be in attendance for 9 sessions. These sessions will be a combination of school
days and days when school is not in session. Please refer to the Page 5 for actual dates.
Fill out this application form completely and accurately in the space provided. Do not attach
additional sheets. The application is also available at: http://www.findlayhancockalliance.com
In responding to Questions 2 or 3• You may use a computer, typewriter or black ink pen.
• If using a computer, cut and securely paste each response.
• Use at least a 10-point type beneath its question.
All information provided is subject to verification. False, inaccurate, illegible, incomplete or
reformatted applications will be disqualified.
Submit your fully completed application to your principal by Friday, March 30, 2012.
HANCOCK YOUTH LEADERSHIP
MISSION STATEMENT
The Hancock Youth Leadership program is an investment in the future
of Findlay & Hancock County. Its purpose is to enhance knowledge
and develop leadership skills in a select group of high school
students, motivating them to become positive role models,
active and committed to their civic responsibilities.
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Question One: (10 points)
List activities involving school, community, home and work. Note any special achievements, awards
recognition, or positions held. List only your involvement in activities during your Freshman and
Sophomore Year.
School: Academic and
Point Extracurricular Groups/Clubs,
Value Teams
Special Achievements,
Awards, or Positions Held
Hrs.
Per
Week
Year
Hrs.
Per
Week
Year
Hrs.
Per
Week
Year
Hrs.
Per
Week
Year
4 pts.
Community: Groups/Clubs/
Church/Volunteer
Special Achievements,
Awards, or Positions Held
4pts.
Home: Non-Paying Responsibilities: Assistance with Family
Business, Caregiver, Childcare
1 pt.
Work: Employer
Positions Held, Awards
1 pt.
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Question Two: (10 points)
In the future, how do you see yourself serving others? Consider the four areas from Question One
(School, Community, Home, Work) and elaborate.
Write your response in essay format within the frame.
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Question Three: (10 points)
Inspiration is the guidance or influence exerted directly on the mind and soul of humankind.
Inspiration can come in many forms.
Inspiration synonyms: awakening, creativity, encouragement, incentive,
motivation, stimulation, vision
Who inspires you? Identify one or two people who inspire you. Include in your response concrete examples of
how this person/these people inspire you.
OR
What inspires you? As examples, some people draw inspiration from poetry, ballads or books. Others draw
inspiration from a particular scene in a movie or play. Whatever it is, please identify your source of inspiration and
give concrete examples of how it inspires you.
Select ONE topic and write your essay response within the frame.
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AGREEMENT
We (the applicant, parents(s)/guardian(s) and school official) certify that all information contained in this
application is true and factual. We also agree that if applicant is selected, Hancock Youth Leadership may
use applicant’s name and likeness and any other information or materials provided by applicant to this
program for purposes of news, publicity and advertising in all media. The application may be released to
applicant’s school office.
We understand: If accepted into this program, there is a commitment to full participation and
attendance, understanding that the retreat is mandatory.
2012
2013
July 27 & 28
September 10
October 2
November 1
December 8
January 21
February 18
March 11
April 17
Overnight Retreat, Leadership Skills-Building
Agriculture/Local Government
Health and Human Services
Arts & Media
Service Saturday/Holiday Gathering
Leadership Development/Diversity
Business and Economic Development
Justice & Law
Volunteerism/End of Year Reflection/Evening Graduation
The cost of the program is $200, payable after selection. (This fee covers costs associated with the
program including the opening retreat, speakers, T-shirts, food and transportation.) Please do not let the
cost of the program keep you from applying. Scholarships are available.
APPLICANT INFORMATION
(Applicant’s personal information will remain anonymous to Selection Committee.)
o Male
Applicant’s name
Last name
First name
Middle initial
o Female
(check one)
Home address
Street
City
State
Zip Code
E-Mail (that is read on a consistant basis)
Date of birth (month/day/year)
T-Shirt size (adult S-M-L-XL-XXL)
Name of parent/guardian
Applicant’s phone
Parent/guardian’s work phone
Signature of Applicant
Date
Signature of Parent/Guardian
Date
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CERTIFICATION BY PRINCIPAL/GUIDANCE COUNSELOR
Name
Title
School
Phone
Address
Street
City
State
Zip Code
All 3 statements must be checked for the applicant to qualify for your signature.
The applicant:
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has met the minimum academic requirement of a 3.0 grade point average,
has accurately completed the Hancock Youth Leadership application,
demonstrates a positive attitude, has a good attendance record, exhibits responsible behavior.
I certify that the individual named in this application has my recommendation to apply to Hancock Youth
Leadership.
Principal/Guidance Counselor Signature ________________________________ Date
Please circle the number that best describes this applicant.
Responsible and Conscientious
1
2
Seldom
3
Usually
Confidential Comments (optional):
6
4
5
Always