Note: Fields with an asterisk (*) are required.

I. Trainer and Organization Information

 

Name*
Title
Organization
Address*
City*
State*	Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip*
Phone*
Fax
Email address*
Web Site

Type of organization you are currently working for
(Please check one per category.):

Agency	Region	Function
non-profit	national	direct service
government agency	state	education/awareness
k-12 school	city	policy/research
higher ed	neighborhood	community development
other	other	other

Home or Secondary Address

 

Address
City
State	State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip
Phone

Please answer the following questions. Questions one and two refer to your organizational capacity and the community environment in which you will be implementing the Institute. If you are applying with a colleague, you may answer these questions as a pair. Questions three and four refer to your personal experience. Each applicant must respond to questions three and four individually. Attach additional pages if necessary. However, please limit your complete response to two (2) pages.

II. Program Implementation

1. In what city, county, community or school do you plan to implement The Points of Light Youth Leadership Institute? (Please be specific). Please describe where you will recruit a diverse group of 25-30 young people to participate in the program. When and how often do you plan to conduct the Institute?

2. How do you plan to gain community support? What other organizations will you work with? Will this program compete with other youth programs in your community?

III. Trainer Experience

3. Describe your experience working with high school-aged youth where your role was a teacher, trainer, or facilitator. Please indicate number of years in this role.

4. Please provide any other relevant information about yourself that you would like us to know about you for the selection process (if you choose, include a resume).

5. How did you hear about the Institute?

Received Brochure
Newspaper Article
Word of Mouth
Internet
Other

IV. Verification

Type the characters you see in the picture below.

 

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