Leadership for America Application | Sauganash Study Center

Personal Information

Name*

First Last

Mother's Name*

Father's Name*

Address*

Street Address City State ZIP Code

Home Phone Number*

Cell Phone Number

Phone Number of Parent (for emergencies)*

Applicant Email Address*

Parent Email Address*

Date of Birth*

Education

School*

Grade Point Average*

Extracurricular Activities*

Miscellaneous

Medical Insurance Company*

Medical Insurance Group Number*

Medical Insurance Policy Number*

Medical Insurance Phone Number*

Electronic Signature for Medical & Photo Release*

As the parent or legal guardian of the participant identified on this application, I hereby delegate authority to the Directors of "Leadership for America" to arrange whatever medical treatment they deem necessary for him during the activity. Also, I hereby authorize and consent to the use and reproduction by Sauganash Study Center staff or an authorized agent or assignee of any and all photographs taken of the above-named applicant for the purpose of promoting Sauganash programs, without any compensation to me. All photos, together with any prints, shall constitute property of Sauganash, solely and completely.

Reference*

Who recommended this program to you?

Essay*

Write an essay (e.g. 200 words) on one of the following topics:

1.) Identify someone who has exercised a leadership role in your life and describe his influence.
2.) What quality more than any others makes for a great leader?
3.) What historical figure do you admire as a leader and why?

Applications submitted without an essay will not be considered.

You may want to draft your essay prior to completing the online application and then copy and paste it into the box provided.

Comments

Please include any medical or dietary needs.