Youth Leadership Program Application

My Community

Cooperative Youth Leaders Program Application

"*" indicates required fields

This field is for validation purposes and should be left unchanged.

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Email*

Student Phone Number*

Date of Birth*

Names of Parent(s) or Guardian(s)*

Parent/Guardian Phone*

Parent/Guardian Email*

Name of School you Attend*

GPA*

Emergency Contact - if different than the parent/guardian listed above

Emergency Contact Phone - if different than the parent/guardian phone number listed above

Career Goal*

School Activities*

Please include years of participation, elected positions, special honors, awards and accomplishments.

Extracurricular Activities*

Community, church or any clubs outside of school. Please include years of participation, elected positions, special honors, awards and accomplishments.

Why would you be a good representative for Coast Electric in the Cooperative Youth Leaders program?*

T-shirt Size*

Dietary Needs/Restrictions

Date Completed*