Youth Leadership Program
970-394-9183
(Revised August 2015)
CLASS OF 2015 /2016 APPLICATION
Application DUE DATE THURSDAY, September 3, 2015
Completed applications must be returned to: The Secretary at YOUR High School
High School Leadership (HSL) is a youth-oriented leadership development program for high school
sophomores and juniors to provide them with skills, knowledge, experiences, networking opportunities and
encouragement to become partners for positive change in their communities. Participants in the program
come together one full school day a month to explore a wide range of topics.
HSL is sponsored by the School Community Youth Collaborative (SCYC). All program facilitators and
coordinators have many years of education and youth development experience, and are dedicated to improving
the lives of teens in Montezuma and Dolores Counties.
Specific program topics include:
 Leadership/Followership/Relationships
 Conflict Resolution & Communications
 Problem Solving & Consensus
 Personal Responsibility & Ethics
 Mental Models & Culture
 Time Management
 The program will focus on the Service Learning Model and participants will follow the model to
create and implement a final service-learning project.
Commitment:
Students are asked to make a commitment to the HSL program by participating in each monthly session
throughout one school year. Students have an opportunity to interact with peers from around the area and with
regional community leaders. It is crucial to the overall experience that students participate in every session, since
an important aspect of the program is the camaraderie, networking and team building within the group. We
understand that young people are very busy with school, sports, jobs, and other activities. We encourage you to
seriously consider if you can fulfill this monthly participation commitment and sign up for the program only if it
will work with your schedule.
Tuition:
Tuition for the program is $50.00. This includes all sessions, light breakfast and lunch during sessions and any
entrance fees if required. Some scholarships are available. Students who withdraw from the program after the
first session will not receive a refund.
Transportation:
Transportation to and from sessions is the responsibility of individual students. However, arrangements can be
made if necessary to accommodate needs.
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Parent Night:
As part of our orientation to the program, we hold a parent night before the September retreat to talk with parents
and students about program content (session topics and service learning project), requirements, special needs,
forms that need to be filled out prior to the retreat, expectations, logistics, and scholarships. Parents are an
important component to the success of the participants in the program and we want to make sure you have as
much information as possible to contribute to your child’s success. The HSL coordinator sends out regular
updates on how the sessions are going, future session topics and logistics, and if we need any additional
assistance or information from parents. Parent night will be on Thursday, September 10th, 6:00pm – 7:00pm, at
First National Bank, Cortez. Light refreshments will be provided.
HSL Schedule for the 2015-16 program year
(Sessions take place on the 2nd Wednesday of the month from 8:30am-3:00pm)
Thursday, September 10, 2015 – Parent night at First National Bank, Cortez, CO 6:00pm - 7:00pm
Tuesday, September 15, 2015 – HSL Retreat, Dolores River Campground, 4:30pm – 8:30pm
Wednesday, September 16, 2015 – HSL Retreat, Dolores River Campground
Wednesday, October 14, 2015 – Communication and Conflict Resolution, Dove Creek High School
Wednesday, November 11, 2015 – Problem Solving and Consensus, Dolores Administration Building
Wednesday, December 9, 2015 –Time Management, Mount Lookout Grange, Mancos, CO
Wednesday, January 13, 2016 – Mental Models and Culture, Southwest Open School, Cortez, CO
Wednesday, February 10, 2016 – Personal Responsibility and Ethics, Towaoc Community Center
Wednesday, March 9, 2016 – Service Project, Location TBA
Wednesday, April 13, 2016 –Service Project, Location TBA
Wednesday, May 11, 2016 –Celebration, Red Eagle Ropes Course, Shiprock, NM
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Application
970-394-9183
Completed applications must be returned to: The Secretary at YOUR High School
Application Deadline is Thursday, September 3, 2015
(Please contact us if late applications are necessary. Cindy Houston: 970-394-9183)
(PLEASE PRINT LEGIBLY)
Applicants Name_____________________________________________________________________________
Home Address________________________________________________________________________________
Mailing Address if different_____________________________________________________________________
Home phone__________________________________Applicant cell phone ______________________________
Applicant Email address________________________________________________________________________
Date of Birth_____________________ Sex M_______F______ School__________________________________
Mother/Guardian Name____________________________Email Address________________________________
Mother/Guardian Cell Phone ______________________ Work Phone__________________________________
Father/Guardian Name_____________________________Email Address _______________________________
Father/Guardian Cell Phone ________________________ Work Phone_________________________________
FULL ATTENDANCE BY EACH PARTICIPANT IS EXPECTED
*School attendance credit will be granted for each session attended*
I willingly commit to attending each of the program sessions throughout the 2015-2016 school year.
Signature of Applicant
___________________________________________________Date______________________
Signature of Parent or Guardian______________________________________________Date______________________
Signature of High School Principal___________________________________________Date______________________
Do you receive free or reduced lunch (data collected for grant funding)?
Do you have any special dietary needs of which we should be aware?
If yes, tell us what we can provide.
YES NO
YES NO
Do you have any special health concerns, such as allergies (i.e. food, medications, stings or bites) or disabilities
we can help accommodate for you to attend?
YES NO
If yes, tell us where we can help.
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Please describe WHY you would like to make a difference in your community.
What extra-curricular activities (both school and community) are you involved in?
a. What months do these activities occur?
b. When do these activities occur (during the school day, right after school, evening, weekend,
etc.)?
c. Please attach activity schedule if available.
Completed applications must be returned to:
The Secretary at YOUR High School by Thursday, September 3, 2015.
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