1 WE ARE INVITING FUTURE LEADERS TO APPLY TO ATTEND OUR LEADERSHIP, EMPLOYABILTY, AND ADVOCACY PROJECT (LEAP) EVENT JULY 19th through 28th, 2015 AT TEXAS A&M UNIVERSITY CAMPUS COLLEGE STATION, TEXAS • 40 high school juniors and seniors will be selected from qualified applicants across the state of Texas. • Exciting educational ten-day training program includes a tour of the State Capitol, a meeting with state level officials and one day of mock legislative sessions. ************************************************************* APPLICATION FORM DEADLINE: July 1, 2015 Applicants must complete and submit application 1). Applicants First and Last Name _______________________________________________________________________ 2). Street Address, City, State, Zip Code _______________________________________________________________________ 3). County _______________________________________________________________________ 2 4). Mailing Address, if different than above _______________________________________________________________________ _______________________________________________________________________ 5). Home Telephone Number (XXX) XXX-XXXX _______________________________________________________________________ 6). E-Mail Address _______________________________________________________________________ 7). Name of High School Attending _______________________________________________________________________ 8). Expected Date of Graduation or Graduation Date if Applicable. _______________________________________________________________________ 9). School Mailing Address, City, State, Zip Code _______________________________________________________________________ _______________________________________________________________________ 10). Birth date: mm/dd/yyyy _______________________________________________________________________ 11). Please describe your disability. This information will assist in assuring accessibility. _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ 3 12). Onset of your disability: mm/dd/yyyy _______________________________________________________________________ _______________________________________________________________________ 13). Please check all that apply so that we may make any necessary accommodations: (feel free to add extended details for any necessary accommodations not listed). Deaf (Describe communication type (i.e. sign language, real time captioning) __________________________________________________________________ Hard of Hearing (Describe) _______________________________________________ Developmental Disability (Describe) ______________________________________ Blind Visual Disability (Describe ) ______________________________________________ Learning Disability (Describe) ___________________________________________ Other Health Impairment (Describe) ____________________________________ Mental Health (describe) _________________________________________________ Other (Describe) __________________________________________________________ _________________________________________________________________ 14). Please describe assistive technology and/or specific accommodation needs (i.e. screen reader, large print, sign language, ambulatory needs, etc.) _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ 4 15). Please list current Reading Grade Level. _______________________________________________________________________ 16). Are you currently working with Texas Assistive and Rehabilitative Services Yes (List Counselor's Name and phone number) ___________________________________________________________________ No 17). Please respond to the following: State Senate Representative's Name and District Number ____________________________________________________________________ State House Representative's Name and District Number ____________________________________________________________________ 18). Name of Local News Source(s): List at least one _______________________________________________________________________ _______________________________________________________________________ 19). Below please briefly list your involvement with your school community. This may include any offices held, club memberships, after-school activities or work experiences. List the length of involvement, the grade level you were in at the time of participation, and the name of the adult you worked with for each activity include the name of activity, adult contact, dates from/to, grade level at participation time. Feel free to add additional information in the text box at the end of the application. _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ 5 20). Community/Volunteer Activities (Name of activity, adult contact, dates from/to, grade level at time of activity). _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ 21). Employment Experiences (Employer, dates, position, grade level at time of employment). _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ 22). Please list two individuals (list full name, email address and phone number) who will provide a reference/recommendation for you. References cannot be provided by persons who are related. One reference must come from a community representative (i.e. dars counselor, minister, volunteer supervisor, employer, etc.). _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ 23). Please provide a brief statement about what you hope to learn during the LEAP training? _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ 6 THIS PROGRAM COSTS INDIVIDUALS $3000.00 TO ATTEND. THIS ATTENDANCE FEE COVERS ALL LODGING AND 3 MEALS PER DAY FOR 10 DAYS, ALL TRANSPORTATION TO EVENTS SPONSORED BY THE LEAP PROJECT, AND ALL NECESSARY ACADEMIC/PROGRAM SUPPLIES INCLUDING PROGRAM T-SHIRT. PLEASE PROVIDE BELOW INFORMATION CONCERNING THE PAYMENT OF THE $3000 ATTENDANCE FEE. 24). Please select T-Shirt size. Small Medium Large Extra Large Other (Please provide size) 25). I will receive financial support from the following sources (check all that apply): Private Pay (i.e. parents, grandparents, self) Third Party (i.e. Texas Department of Assistive and Rehabilitative Services, Education Service Center) Other (please provide details) By signing this application, you are providing permission for LEAP admission staff to speak with your references, counselors, former teachers, employers, family members, and others as appropriate specific to the information you completed as part of this application. Thank you for submitting your application for the LEAP program. Signature (Full Name) ____________________________________________________________________ DATE (mm/dd/yyyy) ____________________________________________________________________