Youth Leadership Application (2026-2027)

Student's name:

First Name *

Last Name *

Please include your name, exactly how you would like it to appear on your name tag: *

Address

Address Line 1 *

Address Line 2

City *

Zip/Postal Code *

Home Phone *

Cell Phone *

Cell Phone Carrier (AT&T, Verizon, etc.) *

Student's email *

Date of birth *

Format: M/d/yyyy

School Attending in September 2026 *

Grade in September 2026 *

Preferred method of contact *

Cell Phone Text Home Phone Email

Please check one.

Preferred Pronouns *

He She They Other Prefer not to disclose

Please select one.

Preferred email address for Youth Leadership Program communication (please choose an email address that you check frequently). *

The following questions are used only for statistical purposes:

Race and Ethnic Identification *

Hispanic/Latino White African American Asian American Indian Native Hawaiian/Other Pacific Islander

THIS SECTION MUST BE COMPLETED BY A PARENT OR GUARDIAN

Parent(s)/Guardian(s) Name

First Name *

Last Name *

Parent or Guardian Cell Phone: *

Cell Phone Carrier (AT&T, Verizon, etc. *

Parent or Guardian Home Phone *

Parent or Guardian email *

Preferred method of contact *

Cell Phone Text Home Phone Email

Please check one.

Emergency Contact for Your Child

Name: *

Relationship with Student: *

Phone Number *

Doctor's Name *

Doctor's Phone Number: *

Any special dietary needs, including allergies:

Medications:

Family Income *

Total Family Income = $0-$50,000 Total Family Income = $51,000-$100,000 Total Family Income = $101,000-$150,000 Total Family Income = $151,000+

Please check the appropriate category. *Scholarships are granted to students with little to no family income on a first come/first served basis until funds are depleted.

Fee

The Youth Leadership 2026-2027 program tuition is $350 for the entire year.

If applicable, what barriers would you have upon entering this program?

Examples: transportation, tuition cost, etc.

Each student participating must submit payment prior to the start of the program in September.

A limited amount of tuition scholarships are available to students who demonstrate financial need and a strong commitment to leadership on a first-come/first-served basis until funds are depleted.

Scholarship

A limited number of scholarships for Youth Leadership candidates are available through the Charles S. North Leadership Advancement Scholarship. Please email completed essays to foundation@chamberfdn.org. The submission deadline is 8/1/2026. For information, and to read the guidelines, visit our website: www.dcrcoc.org/youth-leadership-program

STUDENT - Name/Photograph Release

Press organization and the Dutchess County Regional Chamber of Commerce/The Chamber Foundation, and our partnering presenters and hosts, may write stories on the Leadership Connections Program and/or activities and benefit the youth by displaying their achievements. Please indicate whether you will allow your name and/or photograph released to the press. *

My name and photograph may be released to the press My name and photograph may NOT be released to the press

I agree to be an active participant in the Youth Leadership Program (YLP) throughout the school year. I will attend the monthly YLP meetings and actively participate in project work. I will respect the presenters and the other students in the program. If I miss 2 or more YLP sessions, I will make them up by participating in 5 hours of community service time for every missed meeting. *

Please type your name - this acts as your digital signature.

Date of signature *

Format: M/d/yyyy

PARENT OR GUARDIAN

My child had my permission to participate in the Youth Leadership Program. I agree to arrange for transportation for my child to and from YLP sessions. I understand that my child should be at the YLP sessions 10 minutes prior to start time. *

Please type your name - this acts as your digital signature.

Date of signature *

Format: M/d/yyyy