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Leaders for America Yosemite Leadership Intensive Application
Date Selected
Fall 2023 | October 12th - October 24th
First Name*
Last Name*
Business Name
Phone Number
Work Number
Email
Billing Address
Address
City*
State*
Zip Code*
Gender*
Male
Female
Birthdate*
Occupation
Why do you desire to go on the Leaders for America Intensive Trip?
Have you ever gone on a trip like this before?
Yes
No
* Where?
Do you have a criminal record?
Yes
No
* Please explain
How is your health?
Note:This trip will be physically strenuous at times and will involve a lot of walking.
Good
Fair
Bad
Are you on any medications?
Yes
No
If yes please mention
Do you have any food allergies?
Yes
No
If yes please mention
Do you have any valid health or travel insuarnace?
Yes
No
If yes please mention
Photography Release
By clicking accept you agree to the
"Photography Release"
*
Accept
Liability Release and Consent to Travel
By clicking accept you agree to the
"Liability Release and Consent to Travel"
*
Accept
Terms and Conditions
By clicking accept you agree to
"Terms and Conditions"
*
Accept
Payment Information
Due Today -
$600
Total pay -
$1,750
Pay Amount Due
Pay Full Amount
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Leaders For America Youth Collaborative Scholarship Application
First Name*
Last Name*
Address
Street*
City*
State*
Zip code*
Email*
Phone No.*
Date of Birth*
Leaders For America Youth Collaborative Scholarship Application
Date Selected
Fall 2023 | October 12th - October 24th
Name of School You Attend*
Address of School You Attend
Street*
City*
State*
Zip code*
Name of Parent or Legal Guardian*
Name of Parent or Legal Guardian
Is the address of your Parent(s) or Legal Guardian(s) different from your address on the previous page?*
Yes
No
Address of Parent(s) or Legal Guardian(s)
Street*
City*
State*
Zip code*
Please attach a copy of the policy
Please provide a brief essay (250-500 words) answering the question below:
Why are you interested in going on a Youth Collaborative trip? How will development in your leadership skills and abilities help you succeed in years to come? Please share a time when a challenge or obstacle arose and how you were able to deal with the challenge and overcome it.
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DONATION
First Name*
Last Name*
Email*
Phone No.*
Business Name
Donation Amount*
$
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Youth Collaborative Enrollment
First Name*
Last Name*
Address
Street*
City*
State*
Zip code*
Date of Birth*
Email*
Phone Number*
Gender*
Male
Female
Does your spouse approve of you attending this trip (if not attending themselves)?
Yes
No
Marital Status
Married
Single
Emergency Contact
Name
Phone Number
Occupation
Relationship
Why do you desire to go on the Leaders for America Intensive Trip? Have you ever gone on a trip like this before?
Yes
No
Where
How is your health?
Good
Fair
Bad
Are you on any medications?
Any
Yes
No
Do you have and food allergies or food preferences?
Any
Yes
No
Do you have any special needs or medications that should not be administered to you because of dangerous allergic reactions?
Any
Yes
No
Do you have valid health insurance or travel insurance?
Any
Yes
No
Please Attach A Letter of Recommendation
Please attach a copy of the policy
Do you have a criminal record?
Any
Yes
No
Leaders for America Yosemite Leadership Intensive Application
Date Selected
Fall 2023 | October 12th - October 24th
Leaders Commitment
We are committed to serving you! We will do our best to ensure you will have a safe and life-changing experience! Lastly, we are committed to making sure you stay focused, and we will do everything we can to eliminate distractions as they present themselves (i.e. phones, computers, etc.)
I agree to the terms and guidelines of the Leaders Commitment
Liability Release and Consent to Travel
I hereby release and hold harmless Leaders for America and David Ferranti, Its agent, assigns, employees and volunteer assistants from any liability whatsoever arising out of injury, sickness, damage or loss of property of loss of life which make be sustained by myself or the minor named above during the course of said trip sponsored by Leaders For America for the entire duration of the trip.
I agree to the Liability Release and Consent to Travel
Medical Release
I do give my consent for the director or properly appointed staff member of Leaders for America to secure the administration of medical treatment or medication for myself or the minor named above in the case of an emergency, and I do further agree to the performance of such treatment, anesthetics, and operations as in the opinion of the attending physician is deemed necessary for myself.
I agree to the Medical Release
Photography Release
By agreeing to this document, you understand that you may be photographed and/or videoed during the Leaders for America Intensive. Therefore, by agreeing to this document, you are giving Leaders for America permission to use and/or distribute such photographs and/or videos for promotional and other relating purposes. You also state by agreeing to this document that you understand that you will not receive any sort of compensation for any photographs and or videos.
I agree to the Photography Release
Payment Information
Pay Amount Due
Pay Full Amount
