Name of Applicant: ___________________________
North Carolina Youth Leadership Forum
Delegate Application
2015
Deadline: March 15th, 2015
Delegate Dates: Monday June 15-19, 2015
Alternate formats of this application are available upon request.
NCYLF, P.O. Box 12988, Raleigh, NC 27605 (P) 919-833-1117, (F) 919-833-1171 ylfnc@live.com
Alternate formats available upon request
Name of Applicant: ___________________________
North Carolina Youth Leadership Forum
Held at: North Carolina State University
June 15-19, 2015
Supported by: The North Carolina Statewide Independent Living Council, North
Carolina Centers for Independent Living, and North Carolina Council on
Developmental Disabilities, Communication Services for the Deaf and Hard of Hearing
Hosted by: Alliance of Disability Advocates-Center for Independent Living
Run by: Youth with disabilities
The North Carolina Youth Leadership Forum Committee would like to thank you for
your interest in the 2015 event. The Youth Leadership Forum will focus on advocacy,
individual goals, leadership, and independent living skills, while making a change for
your community. Please complete the following forms and return this to the address
below. If you have any questions please feel free to contact us with any questions or
concerns at ylfnc@live.com or 919-833-1117.
Mail or email the application to:
North Carolina Youth Leadership Forum
P.O. Box 12988
Raleigh NC 27605
ylfnc@live.com
Please state which applies:
First Time Applicant
Repeat Applicant
If so, what year(s) did you apply:________
Approximately 20 youth and young adults will be selected
DEADLINE for postmark on mailed application: March 15th, 2015
Applicants must complete ALL parts of this application.
Alternate formats of this application are available upon request.
NCYLF, P.O. Box 12988, Raleigh, NC 27605
(P) 919-833-1117, (F) 919-833-1171 ylfnc@live.com
Name of Applicant: ___________________________
Part A
General Information
Name :
Date
of
Birth: Age:
Race/Ethnicity
(optional):
Parent/Guardian Name (if under age Gender:
18):
Address:
Preferred Contact Method:
Mailing Address (if different from above):
City:
Zip Code:
County:
Email Address:
Phone Number:
Fax Number:
Name of Current School/Workplace:
Other Educational Experiences:
High School:
Dates:
Post High School:
Dates:
Course of Study:
Alternate formats of this application are available upon request.
NCYLF, P.O. Box 12988, Raleigh, NC 27605
(P) 919-833-1117, (F) 919-833-1171 ylfnc@live.com
Name of Applicant: ___________________________
Part B
Disability Information
What is the name of your disability?
__________________________________
How long have you been a person with a disability? (Date):
_______
What accommodation do you receive (such as personal care assistant, sign language
interpreter, communication device, Braille, large print, etc.)?
Please check all that apply (continued on next page):
AUDITORY
Hard of Hearing
Deaf
COGNITIVE
Asperger’s Syndrome
Autism
Down Syndrome
Intellectual Disability
Learning Disability (reading, writing,
math)
Traumatic Brain Injury
MENTAL HEALTH
Anxiety
Attention Deficit Hyperactivity
Disorder
Bipolar
Depression
Obsessive Compulsive Disorder
Post-traumatic Stress Disorder
Schizophrenia
VISUAL
Blind
Low Vision
PHYSICALHARD OF HEARING
Amputation
Cerebral Palsy
Dwarfism Type:
________
Muscular Dystrophy
Osteogenisis Imperfecta
Spina Bifida
Spinal Cord Injury
Spinal Muscular Atrophy
SYSTEMIC
ALS
Cancer
Crohn’s Disease
Cystic Fibrosis
Diabetes
Epilepsy
Fibromyalgia
Grave’s Disease
Heart Disease
HIV/AIDS
Multiple Sclerosis
Parkinson’s
Psoriasis
Rheumatoid Arthritis
OTHER:
Alternate formats of this application are available upon request.
NCYLF, P.O. Box 12988, Raleigh, NC 27605
(P) 919-833-1117, (F) 919-833-1171 ylfnc@live.com
Name of Applicant: ___________________________
Part C
Questions
Please respond to the 5 questions. Responses can be submitted via the following
formats: typed, handwritten, electronic format, or videotaped and should be submitted
via email to ylfnc@live.com or mailed to:
North Carolina Youth Leadership Forum
P.O. Box 12988
Raleigh, NC 27605
Please complete on separate page in no more than 5 sentences per question, and
attach to the application. Please contact if any assistance is needed in completion of
the application via email/phone at ylfnc@live.com, 919-833-1117
1. Why do you want to come to the NCYLF? What strengths can you bring to the
NCYLF?
2. Imagine you have a problem with a fellow delegate, and the two of you don’t get
along. What would you do?
3. Describe the first time you identified with having a disability. How did you feel at
that time? How do you feel now?
4. What are some of your future goals? How are you working to achieve them?
5. Briefly describe your involvement with your school and/or community within the
last five years. This may include any leadership positions, club memberships,
after-school activities, work experiences, volunteering, church groups, youth
groups, etc.
Please make sure that you have responded to all the parts of the questions.
Any incomplete applications will not be considered for participation.
When receiving your response of acceptance status on May 1st, which method do you
prefer?
 Email
 Mail
Alternate formats of this application are available upon request.
NCYLF, P.O. Box 12988, Raleigh, NC 27605
(P) 919-833-1117, (F) 919-833-1171 ylfnc@live.com
Name of Applicant: ___________________________
PART D
Expectation Agreement
If selected, the following are guidelines that are expected from each delegate
that attends the NCYLF during the week of June 15-19, 2014. I agree to follow all
North Carolina State University residential guidelines and regulations pertaining
to my participation in the North Carolina Youth Leadership Forum. If you agree
with the following guidelines, please sign below before submitting the
application.
-
Be respectful
Attending all dates and times of events
No drugs or alcohol
Stay with group or staff through the duration of the NCYLF
HAVE FUN!!!
I hereby agree that the above information may be used to do a criminal
background check for the safety of myself and other participants.
Electronic signatures are accepted.
Applicant Signature:
Date:
_______________________________
__________
Alternate formats of this application are available upon request.
NCYLF, P.O. Box 12988, Raleigh, NC 27605
(P) 919-833-1117, (F) 919-833-1171 ylfnc@live.com