~ Staff use only ~
Application ID #:
Chicano Latino Youth Leadership Project, Inc.
2014 Sacramento Leadership Conference
Student Application
Application packets must be submitted online or US mail post-marked on or before April 11, 2014
To be eligible, you must:
1. Currently be enrolled in a California high school.
2. Currently be in either 10th (sophomore) or 11th (junior) grade.
3. Not have previously attended the Sacramento Leadership Conference as a participant.
SECTION 1: BACKGROUND INFORMATION
Student Applicant:
Last Name
First Name
Middle Initial
Permanent Address:
House number
street name
(Apartment #)
County of California:
__________________________________________________
City,
State
Zip Code
Email Address:
Primary Number: (
)
Birthdate:
/
Secondary Number: (
/
Month
)
Gender:
Date
Male
Female
Year
Parent/Guardian Name:
Parent/Guardian Name:
Phone Number: (
Phone Number: (
)
Highest education level completed (check one):
)
Highest education level completed (check one):
Middle School or less
Did not finish High School
Middle School or less
Did not finish High School
High School Diploma
Trade Certification
High School Diploma
Trade Certification
Some college
Associate’s Degree
Some college
Associate’s Degree
Bachelor’s Degree
Graduate Degree or Higher
Bachelor’s Degree
Graduate Degree or Higher
Unknown/Declined to state
Unknown/Declined to state
Occupation:
Occupation:
Do any of your family members belong to a union? If
so, which one?________________________________
High School:
Current Grade level:
Current cumulative GPA, weighted:__________________
Check ALL interests:
CSU
Community College
Private College
Did you apply to SLC last year?
Accepted and did not attend
UC
10th grade
11th grad
* YOU ARE REQUIRED TO COMPLETE THIS SECTION *
Find this information at (916) 654-0185
http://www.leginfo.ca.gov/yourleg.html
Out-of-state College
CA State Senator for your zip code
District #
Assembly Member for your zip code
District #
No
Alternate
Did you attend the SJVI or LAI last year?
Denied
Yes
No
Ethnicity: Select all that apply
African American/Black
Filipino/Filipino American
Vietnamese/Vietnamese American
Native American/Alaska Native
Japanese/Japanese American
White/Caucasian/Euro American
Chinese/Chinese American
Korean/Korean American
Other:
East Indian/Pakistani
Mexican/Mexican American/Chicano
Decline to state/Don’t know
Pacific Islander
Family Income:
$24,490 or less
$34,951-$37,350
$60,001-$70,000
$100,001 or more
$24,491-$28.750
$37,351-$40,000
$70,001-$80,000
Decline to state
$28,571-$32,450
$40,001-$50,000
$80,001-$90,000
$32,451-$34,950
$50,001-$60,000
$90,001-$100,000
How did you hear about this program?
Website
Family member
Check all that apply
Guidance Counselor/Academic Advisor
CLYLP Alumni
Teacher
CLYLP Volunteer
Principal/School Administrator
Legislative Office
Email
Other
If an individual, please list their information:
Name:___________________________
Occupation:__________________________
Email:______________________
SECTION 2: EXTRA CURRICULAR ACTIVITIES LIST
On a separate sheet, please list any extracurricular activities you are or were involved with including student leadership,
school clubs, school programs (AVID, PUENTE, etc.), sports, other after school activities, employment experience,
volunteer experience, internships, religious activities, or describe any other responsibilities you have (i.e., babysitting
siblings, helping parent’s business) outside of school. Include the following information for each activity:



List offices or positions held within activity;
Include the grade level(s) and duration of your participation;
Approximate hours per month of activity.
SECTION 3: LETTERS OF RECOMMENDATION
Please submit two letters of recommendation. Make sure both letters include a phone number and contact information. If
possible, letters should be on official letterhead.


One letter must be from an educator (i.e. teacher, counselor, principal, etc.) at your school.
One letter must be from an adult community member who is not related to you. Example of community member:
community organization representative, church or religious leader, employment supervisor, etc.
Send the letters along with your completed application and supporting documents. DO NOT mail the letters of
recommendation separately.
SECTION 4: OFFICIAL HIGH SCHOOL TRANSCRIPT
Please submit an official copy of your most recent high school transcript. Send it along with your completed application
and all supporting documents. DO NOT mail your transcript separately.
SECTION 5: THREE (3) ESSAY QUESTIONS
Please provide complete responses to ALL THREE questions listed below. Each essay should be 500 words or less.
Essays written in Spanish are acceptable. Type or write legibly. Make sure you include your full name and the question
number at the top right hand corner of each essay. Completed essays must be sent with your completed application.
Essay #1 – Leadership: Discuss your Leadership ability and potential. Provide example(s) of when you demonstrated
leadership. How do you see CLYLP playing a role in your leadership development?
Essay #2 – Autobiography: Describe the world you came from--for example your family, community or school--and tell
us how your world has shaped your dreams and aspirations. What is an experience that has occurred in your life that is
important to you and why?
Essay #3 – Hypothetical Situation: Imagine yourself as a future leader of California (i.e., Lawmaker, Community Leader,
Business Leader). Identify key barriers or challenges that California must overcome to ensure all K-12 students have the
opportunity to access and succeed in higher education. What skills will you need, as a future leader, to be prepared to
deal with these issues? How
SECTION 6: STUDENT AND PARENT/GUARDIAN SIGNATURE
I certify that all the information provided in this form is accurate, that I meet the CLYLP student participation criteria, and
that the CLYLP may verify any information I have provided. I also understand and agree to abide by the CLYLP student
participation, student expectation and student behavior rules should I be accepted to attend the CLYLP Sacramento
Leadership Conference.
__________________________
Student Applicant’s Name (Print)
__________________________________
Student Applicant’s Signature
____________
Date
I give permission to the CLYLP to release information contained in this application to agencies, colleges or universities in
order to provide me with information on college admissions, financial aid, student services, or career opportunities. I
understand that the CLYLP will strive to keep all personal information confidential. I also give permission to the CLYLP to
take photographs of me during program sponsored activities and understand that my photographs may be used for
presentations, publicity materials, and overall promotion of the program.
________________________________
Parent/ Legal Guardian’s Name (Print)
__________________________________
Parent or Legal Guardian’s Signature
____________
Date
Checklist:








1. Application Form
2. Letter of Recommendation – from an educator
3. Letter of Recommendation – from a community member
4. Extracurricular Activities List
5. Official High School Transcript
6. Essay #1 - Leadership Essay
7. Essay #2 - Autobiography Essay
8. Essay #3 - Hypothetical Situation Essay
Submit online or US mail post-marked April 11, 2014:
CLYLP Mailing Address:
CLYLP, Inc.
Student Application Committee
P.O. Box 161566
Sacramento, CA 95816-1566
Online submissions: www.clylp.org
PROGRAM DATES AND LOCATION
The Sacramento Leadership Conference will take place July 19-26, 2014 in the City of Sacramento.
IMPORTANT INFORMATION
 Failure to provide any of the above requested documents may disqualify you from having your application
reviewed.
 Keep a copy of your application and all documents submitted to the CLYLP Application Committee.
 If you are selected to participate in the 2014 CLYLP Sacramento Leadership Conference you will be notified by
early June either by email or phone.
 Check your email and voicemail often and promptly respond to any messages from CLYLP staff.
 Los Angeles County Students: If you are not selected to attend the SLC, you may be invited to participate in the
CLYLP Los Angeles Institute instead. There is no separate application for this program. CLYLP staff will contact
you if selected.
MORE QUESTIONS?
Visit our Frequently Asked Questions page at www.clylp.org for more information about the selection process.
Contact CLYLP via e-mail at [email protected] or (530) 481-5642
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