Leadership Application

Name *

First Name Middle Name Last Name
Date of Birth *

Month Day Year
Date
Marital Status *
Email *
example@example.com
Cell Phone *
Please enter a valid phone number.
Do You Have a US Social Security Number? *

Yes No
How Many Years Have You Been With Us? *
How Many Programs Have You Worked for Us? *
Upload a Picture of You *
School Name *
Why Do You Want to Lead with Us Next Summer/Winter? *
Earliest Date Available *

Month Day Year
Date
HEALTH INSURANCE
Are you covered under a Health Insurance Plan? *

Yes No
Food Allergies? *

Yes No
Please List Allergies
Disclaimer

All students are subject to a background check under the Federal Fair Credit Report Act. Failure to consent to the consumer report, including the criminal record check, will result in ineligibility to participate in our program. You will be asked to sign a consent form authorizing this.
Signature

Clear
Should be Empty:

HEALTH INSURANCE