Great Leaders Make Great Communities!
Youth Leadership Academy 2001-2002
Hancock County High School Juniors
September 20
-
Personalities, styles and profiles in the workplace
Telecommunications – Adams Telephone Company, Golden, IL
October 18
-
Media Forms and State Government
KHQA – Channel 7, Quincy Newspapers, Inc.
Representative and Senator
November 15
-
Entrepreneurship
Method Electronics Inc., Carthage
December 17
-
Hancock County Government
Hancock County Courthouse and Local Government Officials
January 17
-
Leadership Challenges in Community Issues
Carl Sandburg College Branch Campus, Carthage
February 14
-
Agriculture and Rural Illinois
Ursa Farmer’s Cooperative and Colusa Elevator System
Bott Center, Warsaw
March 21
-
Health Care Issues
Burlington Hospital or Blessing Hospital System
April 18
-
Tourism – Big Business in Illinois
University of Illinois Extension – Nauvoo
April 23
-
Graduation Dinner
All sessions begin at University of Illinois Extension, Carthage, and leave for destination at 8:45
a.m. Sessions will end at 1:15 p.m. with return to Carthage varying with the distance from
Carthage.
University of Illinois Extension provides equal opportunities in programs and employment
Great Leaders Make Great Communities!
Youth Leadership Academy 2001-2002
Hancock County High School Juniors
Mission Statement: The Youth Leadership Academy of Hancock County will offer each
participant a unique experiential exposure into the administrative leadership and operating skills
within eight business domains that utilize a variety of systems to deliver products, goods and
services to customers or consumers.
Eligibility Requirements: Students must meet predetermined criteria established by University
of Illinois Extension and the local school district of residence. Students must have maintained a
“C” average for the Freshman and Sophomore high school years to be considered and provided
an Application. All selections for participation in the Academy are determined by the local
school district.
Application Form: It is the responsibility of the student applicant to complete the application
form and to contact each adult who will be submitting a recommendation.
Recommendation Form: Each application must have three letters of recommendation. At
least one recommendation must be from a teacher or school official and one from a non-relative
adult in the community.
Any adult can recommend a student, but they must ensure that the student (nor parent or
guardian) is completing and submitting an application form.
Requirements for Academy Student Members:
1. Applicants must have maintained a “C” average during the first two years of high school.
2. Applicants must be in their third high school year of study (Junior standing).
3. Applicants must be a resident or paying tuition student attending the local district to be
considered.
4. Applicants must remain in school during the year, otherwise, membership in the
Academy ceases when school enrollment ends.
5. Applicants must not have had nor have any difficulties with the law or school to
participate in the program.
6. Applicants cannot be participants in gang activities.
7. Applicants and families must sign the family contract.
Great Leaders Make Great Communities!
Youth Leadership Academy 2001-2002
Hancock County High School Juniors
Student Application Form 2001-2002
Student Name: ________________________________________________ Age: _________
Street Address: ______________________________________________________________
City/State/Zip: _______________________________________________________________
Telephone # where student can be reached: (_______) ______________________________
Best time to be reached: ___________________ Alternate telephone #: _________________
School Name: _______________________________________________________________
With whom to you live? both parents ________ one parent ______ grandparent(s) ________
Guardian(s) ________ other (please explain) ______________________
Complete the following:
1. If you could work anywhere and be anything when you have graduated, what would you
be and why?
2. Who is the person that has had the most impact or influence on your life? What have you
learned from him/her?
3. What do you like best about school and why?
4. What do you like lease about school and how would you improve it?
5. When you are not in school, what do you like to do best to improve yourself? What is it
you like best about it?
6. Please describe any responsibilities you have to help others (at home, school, church,
etc.).
7. Tell us about a time when you have had to help plan, organize or run something where
you had to tell others what to do or get them to cooperate.
Names of persons providing recommendations.
Teacher/School Official: _______________________________ Phone #: _________________
Other Adult: _________________________________________ Phone #: _________________
Other Adult: _________________________________________ Phone #: _________________
If selected for this program, I agree that I will abide by the rules set forth in the Program
Description.
___________________________________________________ Date: ___________________
Student Signature
Parent/Guardian: (this page is to be completed by the parent(s)/guardians(s).
Parent(s)/Guardians(s) Names:
_________________________________________________
last
first
___________________________________________________________
last
first
My child is:
male ________
female ________
(Voluntary)
White _______ Hispanic _________ Black, Non-Hispanic ______
pan-Asian ___________ other _________ (please explain) ____________
If my child is selected for this program, I/we agree that I/we will support him/her in meeting the
Requirements for the Academy Student Members, and that I/we will faithfully endeavor to
participate in the Academy Graduation Ceremony.
I certify that to the best of my knowledge, the above information is correct. I understand that
any falsified information will result in disqualification of the student applicant.
Parent(s)/Guardian(s) signature: _______________________________ Date ____________
______________________________ Date _____________
Deadline for Completed Application:
Delivered to the High School Administrator by 12:00 noon, September 7, 2001.
Incomplete applications will not be accepted.
University of Illinois Extension provides equal opportunities in programs and employment.
Source: Form adapted from Elgin Community College
Great Leaders Make Great Communities!
Youth Leadership Academy 2001-2002
Hancock County High School Juniors
Recommendation Form 2001-2002
Please Print:
Name of student ______________________________________________________________
last
first
Recommender Name __________________________________________________________
Last
first
Recommender Position: teacher/school official ________ community person ______________
Relationship to student _____________________________ Title (if any) __________________
Street Address ________________________________________________________________
City/State/Zip Code ____________________________________________________________
Telephone # recommender can be reached (________) _______________________________
Best time to be reached ________________________________________________________
Alternate telephone #, if available _________________________________________________
RECOMMENDATION:
If you are recommending a student, please contact him/her to ensure that she/he has completed an application.
Please address each of the following:
LEADERSHIP POTENTIAL AND PERFORMANCE:
Registration Information:
Youth Participant: ______________________________________________________________
(First Name)
(M.I.)
(Last Name)
Gender:
 Male
 Female
Years in 4-H: ____________________
Parent’s Name: ____________________________________________________________
(First Name)
(M.I.)
(Last Name)
Address: __________________________________ City: _____________ Zip: _________
Home Phone: __________________________ Parent’s Work Phone: ________________
Birthdate: ____/_____/_____ Age as of 9/1/00: _________Grade Completed: _________
Your Race/Ethnicity:
(check one)
 African-American
 Caucasian
 Latino
 Native American/Alaskan
 Pacific Islander/Asian
Size of the community you live in:
(check one)
 City
 Suburb of one of the cities
 Medium Town (10,000-50,000)
 Rural/Small Town (town under 10,000 or rural
 Farm (income is from farming)
Special Needs/Dietary Restrictions: ___________________________________________________
Parental Consent:
As parents or guardians, we understand the activities and related rules that will be conducted/enforced at
Youth Leadership Academy and agree that our child may participate.
(Parent/Guardian Signature)
(Date)
(Parent/Guardian Signature)
Youth consent:
As a youth participant, I agree to fully participate fully in the activities described and agree to follow the
rules and procedures for a safe, fun, educational event.
___________________________________________________________________________________
(Youth Signature)
(Date)
Photo/Video Release:
I, ________________________, grant University of Illinois Extension programs the permission to
disclose my child’s identity and to reproduce and distribute videotapes, films, photographs, and
transparencies of my child or sound recordings arising out of documenting Youth Leadership Academy.
(Date)
Return this form to:
University of Illinois Extension
550 North Madison
Carthage, IL 62321
(Parent/Guardian Signature)
University of Illinois * U.S. Department of Agriculture* Local Extension Councils Cooperating
University of Illinois Extension provides equal opportunities in programs and employment.