Name*

First Last

Email*

Phone*

Address*

Street Address City State ZIP Code

Date of Birth*

School Currently Attending*

Emergency Contact Name (Parent/Guardian)*

Parent/Guardian Email Address Email*

Parent/Guardian Phone*

Your Gender*

Female
Male

Person with a disability?*

Yes
No

Ethnicity*

American Indian or Alaska Native
Asian
Black or African American
Caribbean American
Hispanic or Latino
White

Is anyone in your family a graduate of an LBF program?

Yes
No

*Please note answering "yes" to this question does not guarantee admission into the program.

Please list all LBF alumni in your family and what program they participated in.

How did you learn about YLB? (check all that apply)

YLB graduate
Guidance counselor/BRACE Advisor
Sibling
Teacher
Principal
Parent
Student club
Other

In order of importance to you, please list up to five school, work, volunteer, religious, social, ethnic or athletic activities in which you are currently involved or have been involved with in the past. Include the following: 1) organization name 2) position held 3) dates 4) brief description of responsibilities and 5) the number of hours per week you contribute(d).*

Why do you want to participate in YLB and what do you hope to get out of the experience?*

Describe a time when you stepped out of your comfort zone. What were the challenges? What did you learn?*

Describe a personally rewarding or memorable experience. What did you learn through this experience?*

What are some of the most troubling issues/problems that YOU face as a teenager today?*

What are some local (Broward County) issues that you would like to learn about and why are these issues important to you?*

Attach Files in PDF (2 Reference Forms, Consent Form, Financial Assistance Forms)

Drop files here or

Max. file size: 2 MB, Max. files: 5.

Attach any additional documents or news clippings here. If you have Consent Form, Reference Form or Financial Assistance Form complete, please attach here or send later to apply@leadershipbroward.org.

As a participant of YLB, you are required to attend a program orientation, opening retreat, graduation (day and evening), at least 4 of the 6 monthly program days which take place on school days, and a mandatory ongoing community service project outside of YLB and school hours. Do you feel confident in your ability to fully commit to the YLB program?*

Yes
No

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