2018 youth leadership forum for students … ylf... · filipino. japanese korean laotian ......
TRANSCRIPT
Youth Leadership Forum Department Of Rehabilitation 721 Capitol Mall Sacramento, CA 95814
(855) 894-3436 (voice) for relay services please call 711 [email protected] (email) Page 1 of 7
CALIFORNIA YOUTH LEADERSHIP FORUM FOR STUDENTS WITH DISABILITIES
2018 YOUTH LEADERSHIP FORUM FOR STUDENTS WITH DISABILITIES DELEGATE APPLICATION
(Event subject to funding availability.)
Only Typed Application Will Be Accepted!
If under 18, my parent/guardian is aware I am submitting this application.
Student Information
First Name Middle Last
With which gender do you identify?
Male Female Other: (write in)
Birth date: (Month, Day, Year)
Home address City & Zip Code: California County of residence:
Applicant’s phone number:
Applicant’s email address:
Parent/Guardian name:
Parent/Guardian’s phone number:
____________________________ _______________________________ Student’s Last Name First Name
Youth Leadership Forum Department Of Rehabilitation 721 Capitol Mall Sacramento, CA 95814 (855) 894-3436 (voice) for relay services please call 711 [email protected] (email)
Page 2 of 7
Parent/Guardian’s email address:
Please specify your race and ethnicity from the checklist. Check all that apply:
American Indian and/or Alaskan Native Asian Group:
Asian Indian Cambodian Chinese Filipino Japanese Korean Laotian/Hmong Vietnamese Other Asian Group
Hispanic and/or Latino Cuban Mexican/Mexican American Puerto Rican Other Hispanic/ Latino Groups
Native Hawaiian or Other Pacific Islander Group:
Guamanian /Chamorro Hawaiian Samoan Other Pacific Islander
Other Groups
Aleut American Indian/Native American
Black / African American Eskimo
White Other Racial Group
Choose not to identify
School Information Current grade level: Sophomore Junior Senior
Current reading level: 5th grade 6th grade 7th grade 8th grade 9th grade 10th grade 11th grade 12th grade Other: (write in)
Anticipated Graduation Date: (month / year)
____________________________ _______________________________ Student’s Last Name First Name
Youth Leadership Forum Department Of Rehabilitation 721 Capitol Mall Sacramento, CA 95814 (855) 894-3436 (voice) for relay services please call 711 [email protected] (email)
Page 3 of 7
School and Community Involvement What activities are you involved in? (e.g. student leadership, club memberships, sports, band or other after school activities, volunteer experience, internships, religious activities or work experiences) Add additional pages if needed.
A. Name of activity:
Name of organization: How long have you participated? (Please check a box) Less than 1 year 1 year or more 2 years or more
B. Name of activity:
Name of organization: How long have you participated? (Please check a box) Less than 1 year 1 year or more 2 years or more
Disability Information Please check all that apply:
Blind/Low Vision / Visual Impairment
Chemical/Environmental Sensitivity
Communication (verbal, speech, other)
Deaf / Hard of Hearing
____________________________ _______________________________ Student’s Last Name First Name
Youth Leadership Forum Department Of Rehabilitation 721 Capitol Mall Sacramento, CA 95814 (855) 894-3436 (voice) for relay services please call 711 [email protected] (email)
Page 4 of 7
Immune (e.g. Crohn’s disease, rheumatoid arthritis, other)
Intellectual/Developmental (e.g. acquired brain injury, down syndrome, epilepsy, cerebral palsy, autism/Asperger’s syndrome and other)
Learning (e.g. dyslexia, dyscalculia, attention deficit disorder, other)
Mental Health/Behavioral Health (e.g. anxiety, depression, bipolar disorder, obsessive compulsive disorder, other)
Mobility / Wheel Chair (e.g. spinal cord injury, muscular dystrophy, other)
Other Disability
Personal Care Attendant: for feeding, dressing, toileting, bathing or
overnight assistance.
Special Equipment needed: a wheel chair, walker, scooter, braille/tablet, etc.
Name of specific disability(s): (write in)
Job Experience Please tell us about your job experience (paid or volunteer)?
What are your plans after high school? Apprenticeship Program 2-year College Degree 4 –yr. College Degree Certification Other: (write in)
____________________________ _______________________________ Student’s Last Name First Name
Youth Leadership Forum Department Of Rehabilitation 721 Capitol Mall Sacramento, CA 95814 (855) 894-3436 (voice) for relay services please call 711 [email protected] (email)
Page 5 of 7
What career fields are you interested in? (Check all that apply) Automotive Business Computer & Technology Culinary Design and Arts Legal & Criminal Justice Medical STEM (Science, Technology, Engineering, Math) Skilled Trades Other: (write in)
Programs and Services You Currently Receive Department of Rehabilitation (DOR): If you are a current DOR client, please provide the following information: DOR Branch Office: DOR Counselor’s Name: DOR Counselor’s phone number: DOR Counselor’s email address:
Transition Partnership Program (TPP): Are you currently receiving services in a (TPP) Program? Yes No
Regional Centers (RC): Are you currently receiving services from a (RC?) Yes No
If you are a DOR, TPP, or RC client, please inform your counselor(s) that you are applying for the YLF.
Essay: Tell Us About Yourself Please answer questions 1-3 below on a separate piece of paper. These questions should be typed using font size 14 and double spaced.
____________________________ _______________________________ Student’s Last Name First Name
Youth Leadership Forum Department Of Rehabilitation 721 Capitol Mall Sacramento, CA 95814 (855) 894-3436 (voice) for relay services please call 711 [email protected] (email)
Page 6 of 7
Area #1: Autobiography Describe your experience as a youth with a disability and how it has impacted the person you are today. Area #2: Leadership In what ways has your disability shaped you to become a leader? Area #3: Your vision for the future How will you use your experiences to shape your future?
Legislative Information
A. State Senate Representative’s Name* District Number
B. State Assembly Representative’s Name* District Number
* You can find this information at http://findyourrep.legislature.ca.gov/
Letter(s) of Recommendation Please attach one or two letters of recommendation to assist us with evaluating your leadership skills. These letters can come from a high school teacher, counselor, administrator, or from a community representative outside of your school. Letters from a relative or family member will not be considered.
Final Preparation
Please use the checklist below to ensure your application packet is complete. Incomplete applications will not be considered.
____________________________ _______________________________ Student’s Last Name First Name
Youth Leadership Forum Department Of Rehabilitation 721 Capitol Mall Sacramento, CA 95814 (855) 894-3436 (voice) for relay services please call 711 [email protected] (email)
Page 7 of 7
Required Items Completed 1. Completed Application 2. Essay 3. One or two Letters of Recommendation
Did anyone assist you in completing this application? Yes No
If yes, please specify who:
Which parts:
How did you hear about the YLF? (Check all that apply)
School Social Media Department of Rehabilitation Counselor Other: (write in)
May we share your contact information with the Youth Organizing (YO!)? Disabled and Proud http://yodisabledproud.org/ Yes No By submitting this application, my parent/guardian and I, authorize this application to be confidentially reviewed by an interviewer and a selection panel which is comprised of the YLF partners. Signature of Student Today’s Date Signature of Parent or Guardian (if student is under 18) Today’s Date Thank you for completing this application. Please e-mail it to: [email protected].
If you need additional assistance in submitting your application, please contact us
(855) 894-3436 (voice) For relay services please call 711 [email protected] (email) Please keep a copy of the application packet for your records.