Dubuque Area Youth Leadership Council
Chapter of National Council on Youth Leadership
895 Main Street, Dubuque IA
APPLICATION FOR YOUTH SALUTE 2012
Application Processing Fee $10.00
Please send your application fee (cash or check) to your DAYLC liaison. Your application will only be processed if payment is
received. If paying with a check, please write your name in the memo blank, if paying with cash, include name with payment.
Application Deadline: Wednesday, February 22, 2012
Complete electronically and send application and essay via e-mail to your DAYLC School Liaison.
It is important you include as much information about yourself as possible focusing on activities of the 9 th, 10th, and
11th grade years.
PERSONAL INFORMATION
Student’s Full Legal
Name (as it appears on your
driver’s license):
Birthdate (month, date, year):
High School:
Home Address:
City:
State:
Home Phone:
Cell Phone:
Zip:
*Student E-mail Address:
Father/Guardian:
Mailing Address:
*E-mail:
Phone:
Mother/Guardian:
Mailing Address (if different
than above):
*E-mail (if different than
Phone:
above):
Cumulative GPA:
Class Rank:
*Forms of communication for the DAYLC program will be via e-mail.
Class Size:
ACTIVITIES FORM
List all activities that you have participated in, identify any leadership position, and how long the position was held.
List all grades involved:
9, 10, and 11, 12 (probable).
School Government
List all grades involved:
9, 10, and 11, 12 (probable).
Publications
List all grades involved:
9, 10, and 11, 12 (probable).
Performance
List all grades involved:
9, 10, and 11, 12 (probable).
Academics
List all grades involved:
9, 10, and 11, 12 (probable).
Social Service
List all grades involved:
9, 10, and 11, 12 (probable).
Athletics
Specific Position Held or Honors Received
List all grades involved:
9, 10, and 11, 12 (probable).
Other Organizations
Specific Position Held or Honors Received
Specific Position Held or Honors Received
(i.e. Class Officer, Student Gov’t Activities)
Specific Position Held or Honors Received
(i.e. Newspaper, Yearbook)
Specific Position Held or Honors Received
(i.e. Band, Chorus, Drama)
Specific Position Held or Honors Received
(i.e. Honor Roll, National Honor Society)
Specific Position Held or Honors Received
(i.e Student Ambassador, Mentor Program)
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AUTHORIZATION FORMS
DAYLC School Liaison Authorization
I verify that this student will be a good representative of our school. If at any time during the process,
and up until completion of the awards ceremony, the good standing of this student is compromised, I
agree to notify Jill Courtney at 563-582-1841 x303.
School Liaison Name (typed): ____________________________
Student Authorization
Upon submitting this form, I agree to participate in all DAYLC activities and meet all deadlines as
requested if I am selected to be a 2012 DAYLC Youth Leader. These activities are as follows:
 March 29, 2012: UD Character Development Day
 September 6, 2012: Clarke Leadership Day
 September 11, 2012: Top 5 Interviews
 September 19, 2012: Awards Ceremony
 October 2012: Top 2 Youth Leaders will attend the Town Meeting on Tomorrow (TMOT):
National Leadership Conference held in St. Louis, Missouri. Date to be announced ASAP.
I understand that if I fail to stay within good academic standing I could lose any and all scholarship
dollars and recognition. I also understand that if I cannot attend the events listed above for any reason, I
could lose any and all scholarship dollars and recognition, including the TMOT.
Student Name (typed): __________________________
Parent/Guardian Authorization
I hereby certify that I am the legal parent or guardian of the above-named participant and that I
understand the purpose and general content of the Dubuque Area Youth Leadership Council activities.
I hereby release the DAYLC employees and volunteers from any liability resulting from injuries or
illness sustained during these activities.
In case of a medical emergency concerning my child, I do hereby extend my permission for any and all
medical treatment deemed necessary by a licensed physician. I am reporting any allergies and/or
chronic illnesses, medications, and dietary restrictions.
__________________________________________________________________________________
__________________________________________________________________________________
Photographic Display Release (please check the box if you consent)
If my son/daughter is selected to be a 2012 DAYLC Youth leader, I hereby consent that my child
will participate in DAYLC photographic electronic display that will be showcased at www.daylc.org.
In order to appear in the electronic display, I understand that I will need to provide a 300 dpi, no
smaller than a 4x6 photo of my son/daughter by August 29, 2012. I also declare that I have legal
authority to grant this permission and I accept all responsibilities. Subject to change.
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Parent Name (typed): _____________________________
ESSAY
Please write a personal essay on the following topic using the criteria listed below:
1. What are your strongest leadership skills and what are you doing to improve your weaker
ones? How will you use your leadership skills to impact your future?
Criteria:
• Your essay should be at least 250 and no more than 500 words, typed and double-spaced.
• Use correct grammar, punctuation, and spelling.
• Use personal anecdotes and observations to explain your points.
type essay here
Questions? Contact your school liaison.
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