Gwinnett Student Leadership Team
2014-2015
2014-2015 Gwinnett Student Leadership Team
Application Check List
Please send the following items
for the three GSLT students from your school
to Nancy Ward
Staff Development
Instructional Support Center
by Wednesday, March 12, 2014:
(1) Student Application including
 student information
 completed writings (A, B, C, D, and E)
 signatures of student and parents
 *signature of principal (please include)
(2) GSLT Standards Form including
 student signature for Statement of Commitment
(3) GSLT Parent Consent/Release Form including
 signatures of student, parents, and notary public
(4) Youth Registration Form
 list of allergies, special dietary needs, and insurance
information
(5) Recent Student Picture (required)
 picture to be published in a GSLT student directory
2014-2015 Gwinnett Student Leadership Team Application
PLEASE TYPE. Final applications due to GSLT by Wednesday, March 12, 2014.
Please provide a completed application and a snapshot of yourself to your principal by ______________.
Student:
Name:
_____________________________________________________________________________
Address:
_____________________________________________________________________________
_____________________________________________________________________________
Home Phone: ___________________________________ Cell Phone: ______________________________
E-mail Address: ___________________________________________________________________________
School:
_____________________________________________________________________________
Parent or Guardian:
Name:
_____________________________________________________________________________
Address:
_____________________________________________________________________________
_____________________________________________________________________________
Telephone:
(residence)____________________ (business)______________________________________
E-mail:
_____________________________________________________________________________
Student Information:
A. List school AND community activities in which you are involved. Please include leadership positions.
B. Briefly describe yourself in a short paragraph.
C. Please attach to this application a short essay on The Importance of Student Leadership. Your
essay should be completely developed (approximately one to two double-spaced typed pages).
D. Briefly describe the role student leadership should play in the continuous improvement of a school.
E. Provide one teacher recommendation focused on your communication and leadership skills.
As an applicant for the Gwinnett Student Leadership Team, I understand my selection
encompasses a commitment on my behalf to attend all student leadership activities and
events. If selected, I understand I am a representative of Gwinnett County Public Schools or
Buford City Schools and the Gwinnett Community. I will conduct myself in an appropriate
manner and represent the high standards of my school, my school district, and the Gwinnett
Student Leadership Team.
_________________________
Student's Signature
_____________________________________
Parent's Signature
_______
Date
__________
Date
_________________________
_______
Parent's Signature
Date
_____________________________________
Principal's Signature
__________
Date
2014-2015 Gwinnett Student Leadership Team Standards
Developed by the 2006 GSLT Senior Class
As a member of the Gwinnett Student Leadership Team, I agree to abide by the following standards:


Devote time and energy to developing my leadership skills as well as the skills of other
students in my school;
Implement and facilitate leadership knowledge acquired through GSLT sessions in my local
high school;

Engage actively and positively in GSLT activities, showing respect for the input, feelings, and
ideas of others;

Communicate actively with teachers, school administrators, GSLT members, and
GSLT Board of Directors;

Attend all scheduled GSLT activities (two unexcused absences will result in dismissal)
including a mandatory GSLT Leadership Retreat on Friday, July 25, and Saturday, July
26;

Adhere to the dress code for scheduled activities; and

Remain alcohol and drug free throughout participation in GSLT.

Engage appropriately in the use of social media forums.
Statement of Commitment:
To maintain the integrity of the Gwinnett Student Leadership Team, I accept the challenges
and responsibilities of being a leader and a role model in all aspects of life. I will show
respect for myself, my peers, my school, my community leaders, the environments in which
we meet, and GSLT. I agree to participate fully for two years; attend all scheduled
activities including the GSLT Leadership Summit on Thursday, May 29, 2014, and the
Leadership Retreat on Friday, July 25, and Saturday, July 26; follow all rules and
regulations; and apply my knowledge and skills to benefit my school and my community.
Furthermore, I understand that failure to uphold the standards outlined for GSLT students
will result in my dismissal from the organization.
____________________________________
Participant's Signature
__________________________
Date
2014-2015 Gwinnett Student Leadership Team
Parent Consent/Release Form
Release Waiver and Indemnification
The undersigned and his/her parent or legal guardian, if the participant is under the age of eighteen
years, do hereby execute this release, waiver, and indemnification for him/herself, and his/her heirs,
successors, representatives and assigns, and hereby agree and represent as follows:
To release the Gwinnett Student Leadership Team (GSLT), and the GSLT Board of Directors and
Advisory Committee members, Gwinnett County Public Schools, Buford City Schools, and Gwinnett
County and their officers, employees, and agents from any and all liability, loss, damage, costs, claims,
or courses of action including, but not limited to, all bodily injuries and property damages arising out
of the sole negligence of Gwinnett Student Leadership Team.
The undersigned further agree to indemnify and hold harmless the said above from any and all
liability, loss, damage, costs, claims, or causes of action, including attorney fees and witness costs,
arising out of the undersigned's participation in the Gwinnett Student Leadership Team.
The undersigned further give permission for the participant to take part in functions and trips and to be
photographed during the two-year program for use in promotional purposes.
_________________________________________
Signature of Student
______________________
Date
_________________________________________
Signature of Parent/Guardian
______________________
Date
Agreement and Consent for Treatment
This is to certify that I, the undersigned parent or guardian, hereby consent to and authorize the
administration and performance of all needed medicines, surgical treatment, and the administration of
any anesthetic which, in the opinion of the attending physician, may be necessary and advisable in the
event of any medical emergencies regarding my son or daughter. I understand that efforts shall be
made to contact the undersigned prior to rendering emergency treatment to the patient.
_________________________________________
Signature of Parent/Guardian
______________________
Date
__________________________________________
Home Phone
______________________
Work Phone
_________________________________________
Signature of Notary
______________________
Date
2014-2015 Gwinnett Student Leadership Team
Youth Registration Form
School _________________________________________________________________
Name ____________________________________________
Male_____ Female_____
Home Address ___________________________________________________________
________________________________________________________________________
Phone _________________________________ Date of Birth _____________________
List Allergies (especially medications):
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
List Special Dietary Needs (including food allergies):
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Health and Accident Insurance Provider _______________________________________
Group Number ________________________________ Policy Number _____________
2014-2015 GSLT Junior Calendar
Tuesday, April 29, 2014 - 4:00-5:30 p.m.
Reception for New Students and Parents
Gwinnett Chamber of Commerce – 1818 Club
Thursday, May 29, 2014
Student Leadership Summit
Peachtree Ridge High School
Friday-Saturday, July 25-26, 2014
Leadership Retreat
Friday, July 29: 9:00 a.m. –8:30 p.m.
Saturday, July 30: 7:30 a.m.–4:00 p.m.
Monday, September 8, 2014 - 7:30-11:30 a.m.
Leadership Development
Gwinnett Chamber of Commerce
Monday, October 6, 2014 - 7:30 a.m.-1:45 p.m.
Gwinnett Chamber of Commerce – Junior Session from 7:30-11:30 a.m.
Leadership Development & Networking Luncheon at The 1818 Club: 11:30 a.m.–1:45 p.m.
Monday, November 3, 2014 - 7:30-11:30 a.m.
Leadership Development
Gwinnett Chamber of Commerce
Monday, January 12, 2015 - 7:30-11:30 a.m.
Leadership Development
Gwinnett Chamber of Commerce
Monday, February 9, 2015 - 7:30 -11:30 a.m.
Leadership Development
Gwinnett Chamber of Commerce
Monday, March 2, 2015 - 7:30-11:30 a.m.
Leadership Development
Gwinnett Chamber of Commerce
Monday, March 30, 2015 - 7:30-11:30 a.m.
Leadership Development
Gwinnett Chamber of Commerce
Sunday, April 19, 2015 – 2:00-3:30 p.m.
Graduation/Celebration
Instructional Support Center - Suwanee, Georgia
Tuesday, April 28, 2015 - 4:00-5:30 p.m.
Reception for New Students
Gwinnett Chamber of Commerce – 1818 Club
Thursday, May 28, 2015
Annual Student Leadership Summit
Friday-Saturday, July 24-25…OR…Friday-Saturday, July 31-August 1, 2015 (TBA)
Annual Leadership Retreat