Leadership UA Youth Program Application
Please print this page or download the application in either the MS Word DOC or Adobe PDF format.
Student Information:
Name:________________________________________________________________________
Address:____________________________________________________ Zip:_______________
Home Phone:__________________ E-mail:_________________________ Cell:______________
Age:__________ Are you a freshman this school year?___________ Where:__________________
Parent/Guardian Information:
Name:_________________________________________________________________________
Home Phone:___________________ E-mail:_________________________ Cell:______________
Name:_________________________________________________________________________
Home Phone:___________________ E-mail:_________________________ Cell:______________
Tell us about yourself. Use more space if necessary.
Activities, sports, hobbies:__________________________________________________________
_______________________________________________________________________________
Community or volunteer involvement:_________________________________________________
_______________________________________________________________________________
What do you hope to gain from your participation in the program?____________________________
_______________________________________________________________________________
Tuition for the program is $250 and covers all program costs and snacks during class. Your enrollment will be confirmed upon receipt of payment. Scholarships are available based on need. Please contact the UALP Executive Director at info@leadershipua.org for additional information.
We understand the purpose of the Upper Arlington Youth Leadership Program and the importance of participation and appropriate behavior in all sessions. We agree to devote the time to complete the program. I understand if I withdraw from the program after the first session date, no portion of my tuition shall be refunded. References may be requested.
Student signature:_______________________________________ Date:______________________
Parent/Guardian:________________________________________ Date:______________________
Please send application and check for $250 made payable to “Leadership UA’ to:
Leadership UA
Mary Ellen Hatch, Executive Director
PO Box 21190
Upper Arlington, Ohio 43221
Space in the class is limited. If your application is not accepted your deposit will be returned.
I understand and agree that participants in the Upper Arlington Leadership Program may be photographed or video taped during the program, an associated activity or event. I hereby give permission for the use of my photo, video and/or film likeness, and name by LUA, activity and event holders, producers, sponsors, organizers and/or their assigns for any legitimate purpose. I will hold the released parties harmless for such use.
