City of Virginia Beach Mayor S Youth Leaders in Action (MYLA)

City of Virginia Beach Mayor’s Youth Leaders in Action (MYLA)

Membership InterestApplication

Mission: Mayor’s Youth Leaders in Action (MYLA) exists to be a positive force in the community through leadership, service, education, and representation.

*PLEASE FILL OUT THE APPLICATION WITH BLUE OR BLACK INKONLY*

Youth Information:

First Name: ______Middle: ______Last: ______

Street Address: ______

City: ______State: ______Zip code: ______

Home Phone: ______Cell Phone: ______

Email Address: ______Grade: (circle one): 6th 7th 8th 9th 10th11th

(Rising juniors must be interviewed by July of their junior year for consideration; seniors are not eligible)

Current School: ______Academy:  Yes No

Birth Date (Month/Date/Year): ______Current Age:______

Parent/Guardian Information

Parent Name: ______

Parent Cell Phone: ______Parent Home Phone (If different from Above):______

Parent Street Address (if different from above):______

Parent Email Address: ______

Emergency Information

Emergency Contact Name: ______Emergency Contact Cell Phone: ______

Emergency Contact Home Phone (If different from Above):______

Emergency Contact Email Address: ______

I understand that this application is for the sole purpose of expressing my interest in the Mayor’s Youth Leaders in Action (MYLA) program. This application does not guarantee admittance to MYLA nor does it guarantee an interview or invitation to meetings/events.

______

Youth Initials Date

Applicant Profile

How did you hear about the MYLA Leadership Program?

______

Why are you interested inMYLA?

______

What do you hope to gain from this experience?

______

Please list any qualities and/or special skills you can bring to MYLA.

______

Whattypes of extracurricular activities are you involved in (including work)? Include any leadership positions held.

______

Signatures:

Applicant Signature:______

Parent Signature: ______

If you have any questions, please contact the MYLA Coordinator, Nicky Vasquez, at or 757-385-0428. Forms must be emailed to or faxed to 757-416-0248 – Attention MYLA.