Please submit the following items to the counseling office by:
Wednesday, February 11 th
(1) Student Application including

Student information

Completed writings (A, B, C, D) – please submit each section typed on a separate page and in order. Teacher recommendations may be submitted directly to Mrs. Burke.

Signatures of student and parents

*Signature of principal
(You do not need this for your initial submission. Mr.
Bray will sign the applications of selected students before
they are sent to the county.)
(2) GSLT Standards Form including

Signatures of student and parent(s) for Statement of
Commitment
(3) GSLT Parent Consent/Release Form including

Signatures of student, parent(s), and *notary public
(It is okay if you do not have the notary public for initial submission)
(4) Youth Registration Form

List of allergies, special dietary needs, and insurance information
(4) Recent Student Picture:

Should be a head shot (a school picture is fine).
May be submitted electronically to Mrs. Burke: amy_burke@gwinnett.k12.ga.us)

2015-2017 Gwinnett Student Leadership Team Application
PLEASE TYPE. Final applications due to Counseling office by February 11th .
Student:
Name:
Address:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Home Phone: ___________________________________ Cell Phone: ______________________________
E-mail Address: ___________________________________________________________________________
School: _____________________________________________________________________________
Parent or Guardian:
Name:
Address:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Telephone: (residence/cell)____________________ (business)___________________________________
E-mail: _____________________________________________________________________________
Student Information (Please put each on a separate page):
A. LIST school AND community activities in which you are involved. Please include leadership positions.
(Response should be a list only.)
B. Briefly describe yourself in a short paragraph. (Response should be limited to one paragraph.)
C. Please identify a student leadership initiative you want to implement in your school and provide an
Action Plan for implementation. Explain why your school needs this initiative as well as steps to ensure its sustainability. Please note there are four components to this prompt: (1) Leadership Initiative; (2)
Action Plan; (C) Need for the initiative; and (D) Steps for sustainability. (Response should be limited to one page.)
D. 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

2015-2017 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 31, 2015, and Saturday,
August 1, 2015;

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 28, 2015, and the
Leadership Retreat on Friday, July 31, 2015, and Saturday, August 1, 2015 (and on similar dates during the senior year) ; 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.
_________________________________________
Signature of Student
_________________________________________
Signature of Parent/Guardian
______________________
Date
______________________
Date

2015-2017 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
______________________
Work Phone
__________________________________________
Home Phone
_________________________________________
Signature of Notary
______________________
Date

2015-2017 Gwinnett Student Leadership Team
Student 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 _____________

2015-2016 GSLT Junior Calendar
Tuesday, April 28, 2015 - 4:00-5:30 p.m.
Reception for New Students and Parents
Gwinnett Chamber of Commerce – The 1818 Club (third floor of the Gwinnett Chamber)
Thursday, May 28, 2015 - 8:00 a.m.-4:00 p.m.
Student Leadership Summit
Peachtree Ridge High School
Friday, July 31 - Saturday, August 1, 2015
Leadership Retreat (location TBA)
Friday, July 31: 8:00 a.m. - 8:00 p.m.
Saturday, August 1: 7:30 a.m. - 4:00 p.m.
Monday, August 31, 2015 - 7:30-11:30 a.m.
Leadership Development
Gwinnett Chamber of Commerce
Monday, October 5, 2015 - 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 9, 2015 - 7:30-11:30 a.m.
Leadership Development
Gwinnett Chamber of Commerce
Monday, January 11, 2016 - 7:30-11:30 a.m.
Leadership Development
Gwinnett Chamber of Commerce
Monday, February 1, 2016 - 7:30 -11:30 a.m.
Leadership Development
Gwinnett Chamber of Commerce
Monday, February 29, 2016 - 7:30-11:30 a.m.
Leadership Development
Gwinnett Chamber of Commerce
Monday, March 28, 2016 - 7:30-11:30 a.m.
Leadership Development
Gwinnett Chamber of Commerce
Sunday, April 17, 2016 - 2:00-4:00 p.m.
Graduation/Celebration
Instructional Support Center - Suwanee, Georgia
Tuesday, April 26, 2016 - 4:00-5:30 p.m.
Reception for New Students
Gwinnett Chamber of Commerce – 1818 Club
Thursday, June 2, 2016 – 8:00 a.m – 4:00 p.m.
Annual Student Leadership Summit
Peachtree Ridge High School
Friday, July 29 - Saturday, July 30, 2016 (tentative date)
Annual Leadership Retreat