2017-18 APPLICATION FORM
WHO ARE WE LOOKING FOR?
High school students from DC Everest Senior High, Newman High School, Wausau West High School, Wauasu East High School, Marathon High School, Mosinee High School, and Northland Lutheran High School.
Participants should:
· Have an interest in sharing their talents and leadership through participation in extra-curricular, volunteer, or community activities.
· Have the ability to set and attain goals as demonstrated by school/community involvement.
· Represent a cross-section of participants with a wide variety of talents and experiences as well as ethnic, minority, and gender diversity.
PURPOSE:
The Wausau Area High School Leadership Program is to inspire tenacious learning of leadership in today’s teens, tomorrow’s leaders. Participants will:
ü Learn and practice leadership skills
ü Build a leadership network
ü Prepare to expand school and civic leadership roles
SPONSORS:
The Department of Public Instruction-Wisconsin Educational Opportunity Programs, area businesses, foundations, and the local school districts sponsor this program so teens have a chance to learn about and practice their leadership skills. The program is modeled after Leadership Wausau/Marathon County.
COST:
The cost of the program is $200. Tuition covers the cost of Camp Manito-wish YMCA, meals, and materials. Scholarships will be provided to any student who may qualify based on financial reasons.
APPLICATION DUE DATE: September 8, 2017
Return the completed application along with the signed Risks and Responsibilities form by August 31, 2017 to:
Kids Voting/Wausau Area High School Leadership Program
625 Stewart Avenue
Wausau, WI 54401
A total of 35-40 students will be selected. Feel free to contact any of these people if you have questions about the Wausau Area High School Leadership Program:
Jason McFarlane / DC Everest Junior High / 715/359-0511Jeff See / DC Everest Senior High / 715/359-6561
Jennifer Aune / Marathon High School / 715/443-2226
Scott Gremminger
Nate Lehman / Mosinee High School / 715/693-2550
Keri Wulf / Newman High School / 715/845-8274
Andrea Stelter / Northland Lutheran High School / 715/359-3400
Joe Svitak / Wausau East High School / 715/261-0650
Cathy Wahl / Wausau West High School / 715/261-0850
Thom Hahn / Wausau School District / 715/261-0525
Sharon Hunter / Wausau Area High School Leadership Coordinator / 715/212 1672
STUDENT COMMITMENT:
To graduate from the Wausau Area High School Leadership program, a participant is expected to attend all the sessions including the opening retreat, the full-day sessions and the closing graduation ceremony as well as complete a class project. Participating school districts have indicated release time will be given if needed. These are the TENTATIVE dates and locations for the 2017-18 program year:
October 9, 2017 / Class Orientation, UWMC, 6:30-8:30 p.m.October 26-28, 2017 / Opening retreat/orientation Trust Building, Camp Manito-wish
November 20, 2017 / Understanding Ourselves and Others, Greenheck Fan-Ramuda Office Building, Schofield
January 22, 2018 / Defining Your Leadership Style in the Public Sector, Marathon County Courthouse
February 23, 2018 / Defining Your Leadership Style in the Private Sector, Greenheck Fan Corporation
March 16, 2018 / Application of Skills and Closure, River Valley Bank
April 12, 2018 / Graduation, UWMC
WAUSAU AREA HIGH SCHOOL LEADERSHIP PROGRAM
APPLICATION FORM
I. Personal Data
Name______
Birth Date ______Male ____ Female____ Year of Graduation______
School currently attending______
Street Address______
City______Zip ______Phone( ) ______
Cell Phone ( )______Email address______
II. Community service among teens today is at an all time high. Why do you think that is so? What is your opinion of service as it relates to leadership, and how will you use these skills learned in this program to increase your own involvement in your school and community?
______
______
______
______
______
III. Current Involvement
List below any clubs or organizations that you belong to in school, church, or the community: ______
Have you been as active in community, civic, or school activities as you would like to be? ___Yes ___No Please explain:______
______
RISKS AND RESPONSIBILITIES - CAMP MANITO-WISH YMCA
Please read the following statements carefully. Initial and have one of your parents initial as needed. Then sign the next form along with your parent and date as well.
Student Initials
/ Parent Initials / RISKS AND RESPONSIBILITIESWe accept the fact that, while the program leaders are skilled and experienced, they cannot guarantee the student’s total safety since some risks are beyond their control. We understand that participants are exposed to risks of nature and to elements over which Manito-wish YMCA, DPI, the Chamber of Commerce, the school, or their employees have no control.
The student agrees to follow all instructions and guidelines given by the Manito-wish and High School Leadership staff, and to act in a safe and responsible manner toward all participants.
We fully comprehend and willingly assume the responsibilities and risk of participating in this program.
We give and grant Camp Manito-wish, DPI, and the school district permission to use pictures of the student for promotional purposes.
I hereby give permission to the physician selected by the Camp Manito-wish YMCA to order X-rays, routine tests, and treatment for illness or injury. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the director, or to any medical facility, to hospitalize, secure proper treatment, and to order injection, anesthesia and/or surgery for me as named above. I accept responsibility for medical/surgical treatment charges which may be incurred on my child’s behalf.
Group health insurance policy number: ______
Group health insurance name:______
Name of policy holder:______
V. Student Commitment: I understand the purpose of the Wausau Area High School Leadership program and if I am selected, will devote the time and energy necessary to complete the program. Even though emergencies do arise, I understand any participant missing more than one session, for whatever reason, will be asked to withdraw from the program and no portion of the tuition will be refunded. I understand the above commitment and agree to this by signing this application.
Student Signature:______Date:______
IV. Parent/Guardian Commitment: I have reviewed the requirements outlined above and support my child’s participation in the Wausau Area High School Leadership program. I understand that the sessions will be held off the high school campus and may require participation during regular school days. In addition, my son/daughter will be responsible for his/her own transportation to the activities except to Camp Manito-wish YMCA.
Parent Signature:______Date:______
WAUSAU AREA HIGH SCHOOL LEADERSHIP SCHOLARSHIP REQUEST
Student Name: ______
Date of Birth: MM/DD/YYYY Gender: q Male q Female Current School Grade Level:
School Attending: ______
Cumulative Grade Point Average: ______
Race/Ethnicity – Please answer both a and b. Check ALL that apply.
a. Is the student Spanish/Hispanic/Latino/a?q No, not Spanish/Hispanic/Latino/a / qYes, Puerto Rican / q Yes, Mexican American, Chicano
q Yes, Cuban / q Yes, other Spanish/Hispanic/Latino/a – print group
b. What is the student’s race? Please check ALL that apply.
q American Indian/Alaska Native – please specify principal WI or Other tribe & reservation
q Asian Indian / q Guamanian or Chamorro / q Native Hawaiian / q White
q Black or African American / q Hmong / q Samoan
q Cambodian / q Japanese / q Vietnamese
q Chinese / q Korean / q Other Asian – please specify
q Filipino / q Laotian / q Other race – please specify
Student Primary Contact Information (primary phone number and address)
Name: Relationship to Student:
Street Address: City/State/Zip:
Home Phone Number: Cell Phone:
Work Phone Number: Student/Contact e-mail:
HEAD OF HOUSEHOLD: Female / HEAD OF HOUSEHOLD: MaleHave you earned a bachelors degree from a four-year college or university?___No ___Yes / Have you earned a bachelors degree from a four-year college or university?___No ___Yes
Does your family qualify for or receive Free or Reduced meals at school? q Yes q No
Does your family qualify for or receive any other forms of state or federal support
(TANF, food stamps, etc.)? q Yes q No
Would you like to be considered for a scholarship to attend this program? q Yes q No
I certify that the above information is true and correct to the best of my knowledge.Student Signature / Date
has my permission to participate in the Wausau Area High School Leadership Program and the information provided will be used solely for program evaluation and program eligibility purposes and will be kept confidential.
Parent Signature / Date1