Attach a photo of
yourself here or send a
digital photo to
dstocker@illinois.edu.
Illini Summer Academies
Planning Committee Application
Please type or print – in ink.
Please check one:
____ Youth Applicant
_____ Adult Applicant
NOTE: Items marked with an “*” do not need to completed by adult applicants.
Name:
Address:
City/State/Zip:
Home Phone:
(
Birthdate:
County:
)
Cell
Phone:
/
/
(
)
Age as of
9/1/2012:
Year in school as of 9/1/2012: 9 10 11 12
College
Email:
College Address (if
applicable):
City/State/Zip:
College Email:
Please list CURRENT Leadership Positions that you hold and the organization (i.e. 4-H, Religious, School
club, Other community group, etc.). Please also indicate if they are local, county, or state leadership
positions.) (Adults, please note any positions that involve you working with young people.)
Please list PAST Leadership Positions that you have held and the organization (i.e. 4-H, Religious, School
club, Other community group, etc.). Please also indicate if they are local, county, or state leadership
positions.) (Adults, please note any positions that involved you working with young people.)
(continued)
Please list what you believe to be the four most important leadership positions you have held and indicate
why you selected those positions:
1)
2)
3)
4)
Which words come closest to describing your personality style/interests (Select a maximum of three):
Enjoy science, methodical, check out all the alternatives before making decisions
Fun-loving, risk-taker, enjoy coming up with new ideas
Love technology, always on computer, games (does not include social networking!)
Outdoors whenever possible, love to camp, be with nature
Organized, live by the calendar
Relationship-oriented, enjoy being with friends
Competitive sports
Music, Dance, the Arts
If you could use three words to describe yourself, what would they be and why?
1)
2)
3)
In your opinion, what is your greatest fault?
If you could change yourself in any way, what would you change and why?
What do you feel is your greatest strength?
(continued)
3
What skills, talents, abilities, etc. do you have to offer this committee?
What makes you different from any of the other applicants we may have? Why should you be selected?
What aspects of a high school youth conference are most important to you? (i.e. socialization, educational
value, community service, exploration of campus, etc.) How do you see us incorporating these items into
our 3-day program?
Youth Applicants -- One Reference Evaluation (attached form) must be attached to this application. That
reference evaluation must be from a University of Illinois Extension staff member or school instructor. Note
that the forms must be placed in sealed envelopes by the evaluators.
Adult Applicants – These two items must be attached to this application:
 Two Reference Evaluations (attached form) must be attached to this application. One of those
reference evaluations must be from someone who has witnessed your work with young audiences.
Note that the forms must be placed in sealed envelopes by the evaluators.
 Completed University of Illinois Extension Volunteer Application, CANTS Check Authorization
Form, and Conviction Information Name Check Request Form. If you have already completed
these forms for a local Extension office, photocopies of the forms are acceptable (providing that the
form has been completed within the past 4 years.)
If selected, I realize that I am required to attend 2 face-to-face meetings and a minimum of 4
teleconferences during the coming year AND the 2013 event (dates still to be determined). Committee
members are required to arrive a day before the Academies start for set-up. I also realize that should I
fail to meet these requirements that I will be dismissed from the committee.
Applicant Signature:
Parent/Guardian Signature:*
Extension Staff or School Instructor Signature:*
Must be postmarked no later than August 1, 2012. Send to: Deb Stocker, State 4-H Office; 801 N.
Country Fair, Drive, Suite E, Champaign, IL 61821. FAX, 217/333-9287. E-mail: dstocker@illinois.edu.
Illini Summer Academies Planning Committee
Reference Evaluation
Name of Applicant
Name of Evaluator
Address
City, State, Zip
Circle one:
Extension Staff
4-H Volunteer
High School/College Instructor
Other:
Evaluator, please rate the applicant on the following (U - unknown and 1-poor to 5-excellent). For a Youth applicant,
please complete only the first two sections; for an Adult applicant, please complete the entire form. Each evaluator should
place the completed form in a sealed envelope with the applicant’s name on the front and the evaluator’s signature across
the seal. Envelopes should be returned to the applicant for attachment to the application.
Unknown Poor
Excellent
Ability to work w/ different and diverse audiences (i.e. adults,
younger children, ethnic groups, etc.)
U
1
2
3
4
5
Willingness to work with others, regardless of diversity within a group.
U
1
2
3
4
5
Does fair share of work on joint projects
U
1
2
3
4
5
Serves as an appropriate role model
U
1
2
3
4
5
Communicates ideas effectively.
U
1
2
3
4
5
Ability to get others to work together; compromise.
U
1
2
3
4
5
Volunteers to assist; carries through with responsibilities; knows
when to say “no”.
U
1
2
3
4
5
Attitude (i.e. positive, professional, not arrogant.)
U
1
2
3
4
5
Appearance (neat, well-groomed)
U
1
2
3
4
5
Accepts/completes work assignments.
U
1
2
3
4
5
Exhibits enthusiasm in regard to performing needed tasks.
U
1
2
3
4
5
Exhibits appropriate behavior in public venues.
U
1
2
3
4
5
For Adult applicants only:
Ability to work alongside teens in a partnership
U
1
2
3
4
5
Provides guidance to youth in a professional manner
U
1
2
3
4
5
Enjoys working with teens and has extensive experience doing so
U
1
2
3
4
5
(does not “take over” discussions or tasks)
Please add any additional comments regarding this applicant on the reverse side.
Signature of Evaluator:
Date: