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RYL 2010 Application
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INSTRUCTIONS
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Please complete each section in full and print
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Application must then be signed by the
principal, parent/guardian and student.
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Send completed application to:
Attention: Joni Huffmyer.
Regional Youth Leadership
Northern Kentucky Chamber of Commerce
PO Box 17416
Ft. Mitchell, KY 41017-0416
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Application must be postmarked no later than
March 20, 2009.
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Call or email questions to
Joni Huffmyer at (859) 578-6398
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All questions must be completed for the
application to be accepted.
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PROGRAM SELECTION
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Participation in Regional Youth
Leadership is open to those students
living in the Northern
Kentucky and Greater Cincinnati area who will be
juniors in the 2009/2010
school year.
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The Regional Youth Leadership Selection
Committee, based on the information completed on
the application, will select participants. The
committee will be seeking representation from a
cross-section of the community.
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Applicants must have the full support of the
school they represent and their parent/legal
gaurdian.
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Attendance at all of the sessions is expected.
Excused absences include illness and/or school
commitment. It is MANDATORY that you attend the
Orientation and the Opening Retreat. Please
check the tentative session dates. This will
give you an idea of the commitment that you will
be making from August 2009
to March 2010.
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All applicants will be notified of selection by
April 24, 2009.
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Last Name*
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First Name* |
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Middle Name: |
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Name for Name Tag |
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Home Address* |
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City* |
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State* |
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Zip* |
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Home Phone* |
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Cell Phone |
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Home E-mail |
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School |
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School Contact |
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School Phone |
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School E-Mail |
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OPTIONAL PERSONAL DATA
(this information is helpful in assuring a diverse
class)
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Sex
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Date of Birth |
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Ethnic Background |
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ACTIVITIES
List up to five school activities in which you have
participated during the last four years. |
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High School |
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Name of Club/Organization/Sport |
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Years |
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Your Role |
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Name of Club/Organization/Sport |
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Years |
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Your Role |
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Name of Club/Organization/Sport |
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Years |
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Your Role |
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Name of Club/Organization/Sport |
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Years |
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Your Role |
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Name of Club/Organization/Sport |
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Years |
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Your Role |
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List up to five non-school related activities in which
you have participated during the last four years. |
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Name of Club/Organization/Sport |
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Years |
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Your Role |
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Name of Club/Organization/Sport |
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Years |
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Your Role |
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Name of Club/Organization/Sport |
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Years |
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Your Role |
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Name of Club/Organization/Sport |
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Years |
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Your Role |
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Name of Club/Organization/Sport |
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Years |
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Your Role |
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If you haven't had the opportunity to
participate in such activities, why not? |
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Time
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Not Interested
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Work
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Financial Reasons
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Other
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What is your main interest of studies? |
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QUESTIONS (If working offline, you may type answers
on a separate sheet and attach.) |
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If you could have dinner with anyone, living or
deceased, who would it be and why? |
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In your opinion, what responsibility do youth have
to help solve community problems? |
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If you could change anything in our Greater
Cincinnati/Northern Kentucky region, what would it
be and why?
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Why do you want to participate in Regional Youth
Leadership?
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PARENT/GUARDIAN PERMISSION
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Student Name: |
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School:
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I have read the information
on Regional Youth Leadership and am willing to
have my child participate. I understand it is my
responsibility to provide transportation for my
child to and from the sessions with exception of
the retreat. A bus will be provided to transport
students to the retreat site. In the event that
transportation is required during a session,
Regional Youth Leadership, its agents, and its
employees have my full permission and consent to
transport my child by public school bus, private
automobile, vans or other appropriate means of
transportation.
I hereby release and hold harmless Regional
Youth Leadership, its members, its agents,
employees or any individuals involved in
planning, organizing or presenting programs, for
any accident, injury, illness or any damage
whatsoever related to the above-mentioned
student's attendance at or participation in any
activity or session of Regional Youth
Leadership.
I hereby grant Regional Youth Leadership
permission to photograph my child and to publish
the photos in connection with the advertisement
of RYL including without limitation brochures,
portfolios, flyers, catalogues, compact discs
and websites. |
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Signature of Parent/Legal
Guardian: |
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Print Name: |
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Date: |
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Home Phone: |
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Work Phone: |
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Cell Phone: |
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Email: |
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Emergency Contact: |
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Emergency Contact Phone: |
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SCHOOL PERMISSION |
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All applicants MUST have the
approval their school principal to attend
sessions of Regional Youth Leadership. Please
have your principal sign below. |
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I approve the participation
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in Regional Youth Leadership
for the 2009/2010 school year. |
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Principal Name: |
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School: |
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Principal Signature: |
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Date: |
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ATTENDANCE |
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If selected, you commit to
attend the program orientation, the opening
retreat, each one of the seven program sessions
and graduation. Full attendance by each
participant is essential if Regional Youth
Leadership is to meet its objectives. Regional
Youth Leadership will work with schools to
encourage school attendance credit. Please check
the session schedule. I understand and accept
the attendance requirements for Regional Youth
Leadership. |
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Student Signature: |
_______________________________________________ |
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Date: |
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T-Shirt Size (for Retreat): |
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Other: |
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