leadership, employabilty, and advocacy project (leap) event

1 WE ARE INVITING FUTURE LEADERS TO APPLY TO
ATTEND OUR
LEADERSHIP, EMPLOYABILTY, AND
ADVOCACY PROJECT (LEAP) EVENT
JULY 19th through 28th, 2015
AT TEXAS A&M UNIVERSITY CAMPUS
COLLEGE STATION, TEXAS
• 40 high school juniors and seniors will be selected from qualified
applicants across the state of Texas.
• Exciting educational ten-day training program includes a tour of the
State Capitol, a meeting with state level officials and one day of mock
legislative sessions.
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APPLICATION FORM DEADLINE: July 1, 2015
Applicants must complete and submit application
1).
Applicants First and Last Name
_______________________________________________________________________
2).
Street Address, City, State, Zip Code
_______________________________________________________________________
3).
County
_______________________________________________________________________
2 4).
Mailing Address, if different than above
_______________________________________________________________________
_______________________________________________________________________
5).
Home Telephone Number (XXX) XXX-XXXX
_______________________________________________________________________
6).
E-Mail Address
_______________________________________________________________________
7).
Name of High School Attending
_______________________________________________________________________
8).
Expected Date of Graduation or Graduation Date if Applicable.
_______________________________________________________________________
9).
School Mailing Address, City, State, Zip Code
_______________________________________________________________________
_______________________________________________________________________
10). Birth date: mm/dd/yyyy
_______________________________________________________________________
11). Please describe your disability. This information will assist in assuring
accessibility.
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
3 12). Onset of your disability: mm/dd/yyyy
_______________________________________________________________________
_______________________________________________________________________
13). Please check all that apply so that we may make any necessary
accommodations: (feel free to add extended details for any necessary
accommodations not listed).
Deaf (Describe communication type (i.e. sign language, real time captioning)
__________________________________________________________________
Hard of Hearing (Describe) _______________________________________________
Developmental Disability (Describe) ______________________________________
Blind
Visual Disability (Describe ) ______________________________________________
Learning Disability (Describe) ___________________________________________
Other Health Impairment (Describe) ____________________________________
Mental Health (describe) _________________________________________________
Other (Describe) __________________________________________________________
_________________________________________________________________
14). Please describe assistive technology and/or specific accommodation needs (i.e.
screen reader, large print, sign language, ambulatory needs, etc.)
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
4 15). Please list current Reading Grade Level.
_______________________________________________________________________
16). Are you currently working with Texas Assistive and Rehabilitative Services
Yes (List Counselor's Name and phone number)
___________________________________________________________________
No
17). Please respond to the following:
State Senate Representative's Name and District Number
____________________________________________________________________
State House Representative's Name and District Number
____________________________________________________________________
18). Name of Local News Source(s): List at least one
_______________________________________________________________________
_______________________________________________________________________
19). Below please briefly list your involvement with your school community. This
may include any offices held, club memberships, after-school activities or work
experiences. List the length of involvement, the grade level you were in at the
time of participation, and the name of the adult you worked with for each
activity include the name of activity, adult contact, dates from/to, grade level at
participation time. Feel free to add additional information in the text box at the
end of the application.
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
5 20). Community/Volunteer Activities (Name of activity, adult contact, dates from/to,
grade level at time of activity).
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
21). Employment Experiences (Employer, dates, position, grade level at time of
employment).
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
22). Please list two individuals (list full name, email address and phone number) who
will provide a reference/recommendation for you. References cannot be
provided by persons who are related. One reference must come from a
community representative (i.e. dars counselor, minister, volunteer supervisor,
employer, etc.).
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
23). Please provide a brief statement about what you hope to learn during the LEAP
training?
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
6 THIS PROGRAM COSTS INDIVIDUALS $3000.00 TO ATTEND. THIS ATTENDANCE FEE
COVERS ALL LODGING AND 3 MEALS PER DAY FOR 10 DAYS, ALL TRANSPORTATION TO
EVENTS SPONSORED BY THE LEAP PROJECT, AND ALL NECESSARY
ACADEMIC/PROGRAM SUPPLIES INCLUDING PROGRAM T-SHIRT. PLEASE PROVIDE
BELOW INFORMATION CONCERNING THE PAYMENT OF THE $3000 ATTENDANCE FEE.
24). Please select T-Shirt size.
Small
Medium
Large
Extra Large
Other (Please provide size)
25). I will receive financial support from the following sources (check all that apply):
Private Pay (i.e. parents, grandparents, self)
Third Party (i.e. Texas Department of Assistive and Rehabilitative Services,
Education Service Center)
Other (please provide details)
By signing this application, you are providing permission for LEAP admission staff
to speak with your references, counselors, former teachers, employers, family
members, and others as appropriate specific to the information you completed as
part of this application. Thank you for submitting your application for the LEAP
program.
Signature (Full Name)
____________________________________________________________________
DATE (mm/dd/yyyy)
____________________________________________________________________