YLA Summer Program 2018

The program is from June 25 - June 29, 2018.

*Any applications received after the deadline will be declined. The deadline for the Summer Program Application is May 13th. Students not accepted into the Summer Program will be deferred and considered for the Fall Program. Accepted applicants will receive further payment and location information. All applications are final and cannot be changed after submission. If you have any questions, please contact Kanu Grover at kgrover@ylamerica.org.

Name *

Name

First Name

Last Name

Gender * Male Female Decline to State

Ethnicity *

Caucasian

Hispanic/Latino

Asian

African-American/Black

Middle Eastern

Native American/Alaskan

Native Hawaiian/Pacific Islander

Decline to State

Other,if so state below

School *

2018-2019 Grade * 9th 10th 11th

Email Address *

Address 1 *

City *

State/Province *

Zip/Postal Code *

Cell Phone *

Cell Phone

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Guardian 1's Name *

Guardian 1's Name

First Name

Last Name

Relationship to Guardian 1 *

Guardian 1's Email *

Guardian 1's Cell Phone *

Guardian 1's Cell Phone

(###)

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Guardian 2's Name *

Guardian 2's Name

First Name

Last Name

Relationship to Guardian 2 *

Guardian 2's Email *

Guardian 2's Cell Phone *

Guardian 2's Cell Phone

(###)

###

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Guardian 1's Highest Level of Educati Did not graduate High School High School Graduate College Graduate Associate’s Degree Master’s Degree Bachelor’s Degree Medical Degree PharmD PhD Other Decline to State

Guardian 2's Highest Level of Education Did not graduate High School High School Graduate College Graduate Associate’s Degree Master’s Degree Bachelor’s Degree Medical Degree PharmD PhD Other Decline to State

What clubs/organizations/sports are you a part of and what positions do you hold if any? Include the year you began and the year you ended (if applicable). *

How did you hear about the program, and were you nominated? *

What change would you like to see in your community? (150 words max) *

What are you passionate about? (150 words max) *

What qualities or skills do you possess? (150 words max) *

Describe one defining moment in your life and how did you grow from it? (150 words max) *

Who has inspired you to achieve your goals and how? (150 words max) *

Will any of your activities conflict with the Summer Program?

(Monday, June 25 - Friday, June 29 from 9-1 PM daily)

Yes No

If you answered yes to the question above, please explain why and on which days.

Thank you!