Teen Leadership Rockland 2014-2015
Confidential Application
This Application and letters of reference must be received by Cornell Cooperative Extension, by 5:00 PM
Friday, October 17, 2014. THERE WILL BE NO EXCEPTIONS.
Please email your completed application to Ellen Chorba at etc46@Cornell.edu
Personal Information: (Please type)
*Name (First, MI, Last):
*Address/Town/Zip:
*Home Phone Number:
*Cell Phone Number:
Text Messaging Phone Number:
*Email Address:
Parent/Guardian Information:
*Parents/Guardians Name:
*Parents/Guardians Phone Number:
*Parents Email Address:
School Information: (Please Print Legibly)
*School Name:
*School Address/Town/Zip:
*School Phone Number:
Organizations and Activities:
Please list in order of importance, Community, religious, social, athletic and other organizations in which you
have been a member of. (Include dates and roles)
Experience:
What type of work experience (Paid or volunteer) have you had? Please Describe
*Essay:
In your own words, in approximately 250 words, please describe a specific experience in which you used your
leadership skills to resolve a problem or deal with an issue. The Selection Committee is especially interested in
what you learned from this experience and how you feel about the way you handled it.
* Indicates Response Required
References:
Request two letters of recommendation, one from someone at your school, the other should not be schoolrelated. Family members should not provide recommendations. Please bring these references with you to your
interview.
Attendance:
Participants are expected to attend ALL sessions. If you or your parent/guardian are unable to make this
commitment, it is not in your best interest to apply. Attendance is monitored and absenteeism may result in
dismissal from the program. Other than the Orientation session and the Graduation Ceremony and Dinner, all
classes are held from 3:45-7:45 pm.









Tuesday, November 18, 2014
Tuesday, December 9, 2014
Tuesday, January 6, 2015
Tuesday, January 27, 2015
Tuesday, February 10, 2015
Tuesday, February 24, 2015
Tuesday, March 10, 2015
Tuesday, April 14, 2015
Tuesday, May 5, 2015
Orientation Session
Introduction to Leadership
Media Literacy and Cultural Sensitivity
Public Speaking
Presenting yourself in Public
Understanding the Justice System
Leadership in County Government
Leadership and Group Dynamics
Graduation Ceremony and Dinner
(March 24th, 2015 & April 21, 2015 are the snow dates)
Cost:
A program fee of $150.00 will be due upon acceptance to the program.
* Attendance Policy Statement: (Check the box below to acknowledge your understanding of the Teen
Leadership Rockland Attendance Policy.)
I, the undersigned parent/guardian, understand that the attendance policy for Teen Leadership Rockland
requires my son/daughter to attend all of the sessions, in full, in order to receive a Certificate of Completion. I
recognize that there are no excused absences accepted nor early dismissals or late arrivals granted for my
son/daughter.
* Name of Applicant
* Name of Parent/Guardian
Applicants will be informed by mail as to the status of their application.
For additional information contact:
Kara Lindstrom, 4-H Program Educator at 845-429-7085 ext. 103 or kal269@cornell.edu.
Thank you for your interest in Teen Leadership Rockland.
You May Mail your application to:
Cornell Cooperative Extension of Rockland County
Attention Kara Lindstrom
10 Patriot Hills Rd
Stony Point, NY 10980