to the Lafayette Junior Leadership application.

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Please submit one photograph with this application. Submit complete application by Friday, March 20, 2015.
Application be submitted via email to [email protected] Or by US mail to Lafayette Junior Leadership c/o One Acadiana, 804 East Saint Mary Boulevard, Lafayette, LA
70503.
PERSONAL INFORMATION
Full Name:
Home Address:
City:
Zip:
Phone:
Email:
Preferred Name/Nickname:
Gender:
Birthplace:
Race:
Birthdate:
Parents/Step-parents names:
SCHOOL
Name of Current High School:
Other High Schools Attended:
Main Area of Interest in Studies:
Organizations/Activities: List in order of importance to you²School, Volunteer Religious, Sports, or other activities
or organization in which you have participated during the last four years.
Organization/Activity
Year
Position Held
Hours of
commitment
per month
CIVIC ACTIVITIES
A. In what civic/church/community activities do you participate outside of school?
B. What do you consider your most important achievement thus far?
C. Please list any recognitions, special awards or honors for community, school, church, or academic activities
you have received.
WORK
List any work experience, paid or volunteer, and briefly discuss what it involved.
GENERAL INFORMATION
A. List three reasons why you want to participate in Lafayette Junior Leadership.
B. List three current significant problems facing Lafayette Parish today.
C. List a solution to at least one of the problems you listed in B above.
D. Name three of the most notable and meaningful opportunities that you believe Lafayette has to offer.
E. What are two important problems facing WHHQDJHUVLQWRGD\¶VVRFLHW\"
F. What are your long-range goals? What role do you see for yourself in seven years (whether in school,
business, politics, community, family)?
COMMITMENT
To complete the Lafayette Junior Leadership program, a participant is required to commit to attend the following
sessions during the course of the year:
Opening Retreat (1 Full Day) Required* ± August 16, 2015
Eight (8) Sessions ± September-April, 2ND Wednesday of every month unless otherwise noted
Graduation ± May 13, 2016
*You MUST attend the Opening Retreat in order to participate, no exceptions. An orientation will be held before
the end of the 2015 school year to introduce the students to one another and explain the program rules and
logistics. Details about the opening retreat will be provided at this time.
Attendance is mandatory for all sessions. Excused absences are limited to one session OR two half days and
must be documented by parents and school faculty. If more than one session OR two half days are missed,
participant will not be allowed to continue program or graduate from LJL. Tuition will not be refunded.
TUITION
Tuition for the program is $150.00 per participant. Scholarship applications are available and will be considered
for students in need of financial assistance. Tuition is due upon acceptance into the program. If tuition is not
paid in full by the retreat, the student will be removed from the class.
Applications are due Friday, March 20, 2015.
Please submit via email to [email protected] or by US mail to: Lafayette Junior Leadership c/o One
Acadiana, 804 East Saint Mary Boulevard, Lafayette, LA 70503.
AGREEMENT
Student/Parent Commitment:
I agree to the attendance policy and commitment.
As parent of the applicant I (we) approve of my (our)
FKLOG¶Vparticipation and commitment to Lafayette Junior
Leadership.
__________________________________________
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____________________________________________
3DUHQW¶V, 3DUHQWV¶RU*XDUGLDQ signature
School Commitment:
This student, ____________________________, has approval from this school to participate in Lafayette Junior
Leadership Program.
Authorized Signature/Title/ Date
REFERENCES
Two references are required. Please give one reference form to your high school principal or counselor. Have
the second reference form completed by any adult who knows the student well, other than a parent or relative.
Example: a teacher, scout leader, church youth leader, etc.
It is WKH VWXGHQW¶V UHVSRQVLELOLW\ WR LQVXUH WKDW ERWh reference forms are delivered on time. Application and
references are due by Friday, March 20, 2015 to [email protected] or by regular mail to: Lafayette Junior
Leadership, 804 East Saint Mary Boulevard, Lafayette, LA 70503.
1. Name of Principal or Counselor:
Telephone:
Mailing Address:
Email Address:
2. Second Reference:
Mailing Address:
Email Address:
Telephone:
REFERENCES
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Last
First
Middle
School:
To the Reference: The student named above is an applicant of Lafayette Junior Leadership. The Selection
Committee assigns considerable weight to the statements made by the references of the applicant. The
committee is aware of the time necessary to prepare such an assessment and gratefully acknowledges your help.
Please submit via email by March 20, 2015 to [email protected] or by US mail to: Lafayette Junior
Leadership c/o One Acadiana, 804 East Saint Mary Boulevard, Lafayette, LA 70503.
Your Name:
School/Firm/Organization:
Position/Title:
Email Address:
Phone:
Mailing Address:
A. For how long and in what capacity have you known the applicant?
B. :KDWGR\RXFRQVLGHUWKHDSSOLFDQW¶VSULPDU\ talents and strengths?
C. What do you consider his/her chief weaknesses?
D. Please use the scale below to compare the applicant with other high school sophomores you have known.
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Character
Dependability
Leadership Potential
Initiative
Ability to work with Others
Maturity
Oral communication skills
Persistence and Drive
Interest and Community Affairs
Problem Solving
Excellent
Average
Poor
Unable to
Judge
REFERENCES
6WXGHQW¶V1DPH
Last
First
Middle
School:
To the Reference: The student named above is an applicant of Lafayette Junior Leadership. The Selection
Committee assigns considerable weight to the statements made by the references of the applicant. The
committee is aware of the time necessary to prepare such an assessment and gratefully acknowledges your help.
Please submit via email by March 20, 2015 to [email protected] or by US mail to: Lafayette Junior
Leadership c/o One Acadiana, 804 East Saint Mary Boulevard, Lafayette, LA 70503.
Your Name:
School/Firm/Organization:
Position/Title:
Email Address:
Phone:
Mailing Address:
A. For how long and in what capacity have you known the applicant?
B. :KDWGR\RXFRQVLGHUWKHDSSOLFDQW¶VSULPDU\WDOHQWVDQGVWUHQJWKV"
C. What do you consider his/her chief weaknesses?
D. Please use the scale below to compare the applicant with other high school sophomores you have known.
7UDLWźź
5DQNLQJŹŹ
Character
Dependability
Leadership Potential
Initiative
Ability to work with Others
Maturity
Oral communication skills
Persistence and Drive
Interest and Community Affairs
Problem Solving
Excellent
Average
Poor
Unable to
Judge