Alaska Youth Leadership Forum Participant Application Δ FacebookThis field is for validation purposes and should be left unchanged.Please select the program for which you are applying:(Required)– Please select –Youth Leadership ForumPerson Centered Planning WorkshopFirst aid/CPR certificationYouth RISEFIREApplicant Name(Required) First Last Preferred Name First Email(Required) Applicant Phone #(Required)Date of Birth(Required) MM slash DD slash YYYY Applicant Age(Required)14-1718-24This field is hidden when viewing the formApplicant Age (14-24)(Required)Please enter a number from 14 to 24.Parent/Guardian Name(Required) First Last Parent/Guardian Name First Last Parent/Guardian Email Parent/Guardian Phone #Residence Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State (all participants must reside in Alaska) ZIP Code Mailing Address (If Different from Above) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Applicant Ethnicity American Indian or Alaska Native Asian Black or African American Hispanic Native Hawaiian or Other Pacific Islander White Other Other Ethnicity:A disability is a physical, mental, intellectual, sensory, or medical condition that substantially limits one or more major life activities. Disabilities can be visible or invisible, temporary or permanent, and may affect mobility, communication, learning, cognition, mental health, ability to work, ability to socialize or overall health.What is your disability/disabilities? (please be as specific as possible)(Required)What challenges do you experience due to your disability/disabilities? Describe what area(s) of your life are affected.(Required)Are you a student?(Required) Yes No Other Applicant Current Grade or Education Level(Required)– Please select –8th Grade9th Grade10th Grade11th Grade12th GradeCurrently in collegeCollege graduateTrade & vocational schoolGEDExpected graduation date MM slash DD slash YYYY Name and City of School AttendingWhat is the Highest level of education you have completed?– Please select –11th grade12th gradeSome CollegeAssociates DegreeTrade & Vocational schoolOther"Other" student — please explainDo you have any food allergies or sensitivities? No known allergies or sensitivities Milk/Dairy Eggs Nuts (e.g., peanuts, almonds, walnuts, cashews) Wheat/Gluten Other Please check all that apply.Please specify "other" allergies/sensitivities:Does the SILC need to be aware of any medications you take? If yes, please explain. Accommodations, Support, Technology Individualized support, assistance, and resources will be celebrated and honored, and a variety of avenues for self-expression and interaction will be embedded throughout Alaska Youth Leadership Forum (YLF).Please check the boxes below that are true for you. Your responses are to assist us with planning, and do not impact your opportunity to participate in any way:(Required) I will need an ASL Interpreter to participate in Alaska YLF I will need Captioning to participate in Alaska YLF I will need support with reading, writing, or typing to participate in Alaska YLF I use a screen reader, or other form of assistive technology that will need to be checked for compatibility prior to participating in Alaska YLF I have a tablet or laptop I can bring to use at Alaska YLF I need a tablet or laptop supplied to me for Alaska YLF I don’t need any accommodation. I need an accommodation not listed Please list AccommodationExpectations for Success All Participants at the Alaska YLF conferences are expected to contribute to a positive and productive culture, and must: Communicate with Alaska YLF Conference planning team members regarding conference logistics and return of required documentation. Return all required information by established deadlines, and prior to participation. Adhere to all Health and Safety Protocols prior to and during the conference. Prioritize Alaska YLF, and plan to be fully present for all conference activities. Maintain an equitable and respectful attitude toward peers, presenters, and facilitators. Headsets, radios, electronic devices, and cellular phones that are not being used for participation in Alaska YLF are not permitted during scheduled Alaska YLF activities. Use of such items will be permitted during designated breaks unless their use has been identified as a reasonable accommodation. Parents/Guardians/Other Supporters will be asked to allow youth time and space, free from interruption, throughout the Alaska YLF conference, to maximize their opportunity to learn and grow, challenge themselves, and engage to the fullest. Optimal times for checking in will be shared during orientation and in follow up communication. Submission of your confirmation form includes your acceptance of, and agreement to, following these expectations.Did anyone assist you in completing this application? Yes No If yes, please specify whoDid someone refer/encourage you to submit this application? Yes No If yes, please specify whoPlease type your name as you wish it to appear on any certificates of completion(Required)Applicant Signature: By signing my name below, I attest that I understand the information herein, and that this application is accurate to the best of my knowledge:(Required)Parent/Guardian Signature (if applicable): By signing my name below, I attest that I understand the information herein, and that this application is accurate to the best of my knowledge: *Type Parent/Guardian NameAny follow-up information you need, or additional materials required from you will be emailed to you soon. If you have more immediate questions, or if you have difficulty completing this online form, please email: info@AlaskaSILC.org, or call 907-741-2119. We are here to help and support your journey in any way we can!CAPTCHA
